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GERIATRICS 


N  ASC  H  E  R 


GERIATRICS 

THE 

DISEASES  OF  OLD  AGE  AND  THEIR 

TREATMENT 

INCLUDING  PHYSIOLOGICAL  OLD  AGE,  HOME 
AND  INSTITUTIONAL  CARE,  AND  MEDICO- 
LEGAL RELATIONS 


BY 

I.  L.  NASCHER,  M.  D. 

NEW  YORK 

With  an   Introduction  by 
A.  JACOBI,  M.  D. 


WITH  50  PLATES 
CONTAINING  81  ILLUSTRATIONS 


.   .   - 


PHILADELPHIA 

P.   BLAKISTON'S   SON   &  CO. 

1012  WALNUT  STREET 


Copyright,  1914,  by  P.  Blakiston's  Son  &  Co. 


•»   i  -  •  1 
...  . 


THH.MAPIjE.PRE88.YOBK.PA 


PREFACE 

No  American  work  on  senile  diseases  has  appeared  in  over 
thirty  years,  the  last  being  Charcot  and  Loomis'  "Diseases  of 
Old  Age"  published  in  1881.     Even  that  was  not  distinctively 
American  for  it  was  a   translation  of  the  published  lectures 
delivered  in  the  sixties  by  the  great  French  physician  in  La 
Salpetriere,  the  home  for  the  aged  in  Paris,  to  which  were  added 
ten  lectures  by  Doctor  A.  L.  Loomis  of  New  York.     Since  then 
a  lengthy  article  by  Doctor  A.  Seidel  of  Berlin  appeared  in 
Wood's  Monographs  for  March,  1890,  and  there  have  been  a 
go  number  of  journal  articles  on  various  senile  conditions,  but  no 
American  work  dealing  with  the  subject  as  a  whole  has  ever  been 
published.     The    neglect    of    senile    diseases    (except    arterio- 
cj-  sclerosis  which  has  received  some  attention  in  recent  years) 
.  is  evident  from  the  paucity  of  literature  on  the  subject.     The 
>.    cause  of  this  neglect  must  be  sought  in  the  general  mental  at- 
^    titude  toward  the  "aged.     The  spirit  of  veneration  of  ancestors 
sff    and  the  aged,  such  as  exists  in  China,  does  not  exist  among  us. 
i*   The  sentimental  interest  in  the  aged  is  confined  to  the  immediate 
^L    family  of  the  individual  and  there  the  interest  is  often  less  senti- 
•    mental  than  dutiful.     We  realize  that  for  all  practical  purposes 
^    the  lives  of  the  aged  are  useless,  that  they  are  often  a  burden 
V«^to  themselves,  their  family  and  to  the  community  at  large. 
, V  Their  appearance  is  generally  unesthetic,  their  actions  objec- 
>»   tionable,  their  very  existence  often  an  incubus  to  those  who  in 
a  spirit  of  humanity  or  duty  take  upon  themselves  the  care  of 
the  aged.     Those  who  would  deny  that  this  is  the  usual  attitude 
toward  the  aged  need  but  compare  the  treatment  of  the  uncared- 
for  child  with  the  treatment  of  the  uncared-for  old  man,  the 
asylums  for  children  with  the  asylums  for  the  aged,  the  treat- 
ment in  the  home  where  children  and  their  grandparents  entail 
burdens  upon  the  family.     The  physician  views  the  aged  from 
a  different  standpoint.     As  a  humanitarian  it  is  his  duty  to 
prolong  life  as  long  as  there  is  life  and  to  relieve  distress  wherever 
he  may  find  it.     There  is,  however,  a  natural  reluctance  to  exert 


38H 


vi  PREFACE 

oneself  for  those  who  are  economically  worthless  and  must  re- 
main so,  or  to  strive  against  the  inevitable,  though  there  be 
the  possibility  of  momentary  success,  or  to  devote  time  and 
effort  in  so  unfruitful  a  field  when  both  can  be  used  to  greater 
material  advantage  in  other  fields  of  medicine.     Still  these  ob- 
jections are  paltry  when  applied  to  the  physician's  self-imposed 
obligation  to  relieve  distress  and  prolong  life.     There  is  another 
point  of  view  from  which  the  physician  should  consider  the  aged 
and  their  diseases,  that  of  the  scientist,  for  here  is  a  most  interest- 
ing study,  presenting  problems  that  are  intimately  bound  up  in 
the  grand  mystery  of  life  and  death.     In  this  direction  the 
French  and  German  investigators  are  far  ahead  of  their  Ameri- 
can confreres,  not  so  much  in  the  quality  of  work  done  and  posi- 
tive results  achieved,  as  in  the  quantity,  the  number  of  investiga- 
tors, the  many  lines  of  investigation,  and  the  opportunity  afforded 
them  to  carry  on  scientific  research.     There  the  State  takes  an  in- 
terest in  scientific  work,  lending  its  aid,  and  there  is  substantial 
recognition  of  work  accomplished.     The  lack  of  opportunity  to 
carry  on  research  work  in  this  country  except  at  a  heavy  ex- 
pense to  the  individual,  or  else  at  the  sacrifice  of  the  credit  and 
benefit  arising  from  successful  research  work,  is  probably  the 
main  reason  for  the  neglect  of  the  scientific  study  of  senility  and 
its  diseases.     In  recent  years  considerable  work  has  been  done 
in  blood-pressure  investigations,  cancer  research,  arteriosclero- 
sis and  other  factors  related  to  senility  and  its  diseases.     The 
extent  and  depth  of  these  investigations,  which  are  really  studies 
into  the  causes  and  results  of  senile  changes,  and  the  ever-in- 
creasing scope  of  these  investigations,  give  promise  of  ultimate 
success  in  discovering  the  fundamental  causes  of  senescence. 
Perhaps  there  may  be  controllable  causes  or  causes  which  can  be 
minimized  so  as  to  defer  senility  and  prolong  life  to  its  physio- 
logical end.     The  prolongation  of  life  is  after  all  the  aim  and 
goal  of  the  physician's  endeavors.     The  author  acknowledges 
his  deficiencies  both  as  a  writer  and  investigator.     Much  of 
the  histological  and   pathological  data  have  been  culled  from 
other  recent  works,  mainly  German  and  French,  but  their  erudite 
theories  have  been  omitted  except  where  theoretical  discussions 
were  necessary  as  in  the  chapter  on  causes  of  ageing.     In  nomen- 
clature, the  author  follows  the  tendency  of  American  writers 
to  use  English  terms  rather  than  the  more  scientific  but  often 


PREFACE 


VU 


more  complex  and  less  understood  Latin  terms  used  by  Euro- 
peans. A  few  new  terms  are  introduced  where  the  old  terms 
are  complicated  as  "Grawitz'  cachexia"  to  cover  the  disease  he 
described  under  the  name  "fatal  cachexia  without  discernible 
anatomical  cause;"  "Ortner's  syndrome"  for  the  disease  he  de- 
scribed as  "  dyspragia  intermittens  angiosclerotica  intestinalis." 
The  word  senile  is  prefixed  to  diseases  that  present  different  fea- 
tures in  senility  from  those  of  earlier  life.  Other  terms  like  hypo- 
static edema,  psychic  senile  debility,  etc.,  will  be  readily  under- 
stood. The  classification  is  new.  Lengthy  descriptions  have 
been  avoided,  minute  pathology  has  been  generally  omitted, 
and  only  the  essential  symptoms  necessary  to  recognize  a  dis- 
ease and  differentiate  it  from  others  have  been  introduced.  It 
seems  superfluous  to  describe  every  symptom  that  may  appear 
in  a  disease  in  old  age,  which  differs  in  but  a  few  essentials  from 
the  similar  disease  of  maturity,  especially  when  the  physician 
should  know  the  disease  as  it  appears  in  maturity  or  can  get  a 
description  from  the  ordinary  text-books.  Greater  stress  has 
been  laid  upon  the  treatment  of  diseases  and  the  differential 
diagnosis  between  normal  senile  conditions  and  pathological 
conditions  which  they  simulate,  as  this  branch  of  geriatrics  has 
been  generally  neglected. 

In  presenting  this  work  to  the  medical  profession  the  author 
hopes  to  arouse  an  interest  in  geriatrics  and  stimulate  research 
into  the  causes  of  senescence  and  the  pathology  of  senile  dis- 
eases. It  is  not  too  much  to  expect  that  as  a  result  of  such 
interest  and  research  we  will  get  a  better  knowledge  of  the  senile 
organism  and  be  more  successful  in  coping  with  senile  diseases 
than  we  are  at  present.  Believing  that  attention  would  be 
more  readily  concentrated  upon  this  subject  if  it  were  con- 
sidered entirely  apart  from  maturity,  the  author  suggested  that 
it  be  studied  as  a  special  branch  of  medicine  to  which  he  ap- 
plied the  term  geriatrics.  This  term  which  has  been  generally 
adopted  is  derived  from  the  Greek,  geron,  old  man,  and  iatrikos, 
medical  treatment.  The  etymological  construction  is  faulty 
but  euphony  and  mnemonic  expediency  were  considered  of 
more  importance  than  correct  grammatical  construction. 

I  desire  to  express  my  gratitude  to  the  authors  and  radio- 
graphers who  have  furnished  me  with  cuts  and  illustrations  and 
the  permission  to  use  their  illustrations  which  appear  in  this 


viii  PREFACE 

work;  also  to  the  Journal  of  the  American  Medical  Association, 
Medical  Record,  and  New  York  Medical  Journal,  in  which  some 
of  these  illustrations  first  appeared;  and  to  Doctor  Alexander 
Klein  of  Philadelphia  for  his  careful  revision  of  the  entire  work. 

I  would  also  like  to  express  my  gratitude  to  Doctor  Robert 
Abrahams  and  the  Medical  Staff  of  the  Home  of  the  Daughters 
of  Jacob,  New  York,  and  to  Doctor  W.  Travis  Gibb  and  the 
Medical  Board  of  the  New  York  City  Home  for  the  Aged  and 
Infirm,  and  the  General  and  Neurological  Hospital  for  the 
opportunities  given  me  to  study  cases  at  those  institutions. 

Some  of  the  material  in  this  work  appeared  in  the  author's 
papers  which  were  published  in  the  N.  Y.  Medical  Journal, 
Medical  Record,  Medical  Times,  American  Medicine,  American 
Practitioner,  Archives  of  Diagnosis,  Dietetic  and  Hygienic 
Gazette,  all  of  New  York;  International  Clinics  and  Medical 
Council  of  Philadelphia;  and  Am.  Journal  of  Clinical  Medicine 

of  Chicago. 

I.  L.  Nascher. 


CONTENTS 


Pace 

Preface      v-viii 

Introduction  by  A.  Jacobi,  M.  D xi-xiv 

Childhood  and  Old  Age i 

PHYSIOLOGICAL  OLD  AGE .        \  „ 

The  Senile  State 1 1 

Anatomical  Changes  in  Old  Age 21 

Physiological  Changes  in  Old  Age 31 

Causes  of  Ageing 38 

PATHOLOGICAL  OLD  AGE 51 

General  Considerations 51 

Classification  of  Diseases  in  Old  Age 65 

Primary  Senile  Diseases 67 

Senile  Cachexia 67 

Senile  Arteriosclerosis 74 

Senile  Phlebosclerosis 94 

Senile  Degeneration  of  the  Heart 95 

Senile  Myofibrosis 96 

Brown  Atrophy 99 

Senile  Endocarditis 100 

Senile  Degeneration  of  the  Lungs 101 

Senile  Pneumokoniosis 103 

Senile  Degeneration  of  the  Oral  Cavity      104 

Senile  Degeneration  of  the  Stomach 106 

Gastric  Atonicity 106 

Dilatation  of  the  Stomach 108 

Pyloric  Insufficiency 109 

Senile  Degeneration  of  the  Intestines no 

Senile  Constipation no 

Atony  of  the  Sphincter  Ani 113 

Senile  Degeneration  of  the  Liver 114 

Senile  Degeneration  of  the  Gall  Bladder 115 

Senile  Degeneration  of  the  Kidney 116 

Senile  Degeneration  of  the  Bladder 1 1 7 

Senile  Degeneration  of  the  Male  Genitals      120 

Senile  Degeneration  of  the  Prostate I22 

Senile  Degeneration  of  the  Female  Genital  Organs      124 

Senile  Degeneration  of  the  Ductless  Glands I27 

Spleen I28 

Thyroid  Gland I29 

Suprarenal  Glands      I29 

Senile  Degeneration  of  the  Skin I30 

Alopecia x32 

Hypertrichosis *33 

ix 


CONTENTS 

Page 

Canites 133 

Degeneration  of  Sudoriparous  Glands 134 

Senile  Muscular  Degeneration 134 

Senile  Arthrosclerosis 136 

Pseudo  Paget's  Disease 138 

Senile  Degeneration  of  the  Brain 138 

Senile  Degeneration  of  the  Cord      145 

Senile  Myelitis 146 

Senile  Tremor 148 

Senile  Degeneration  of  the  Nerves  and  End  Organs 150 

Senile  Degeneration  of  Organs  of  Special  Sense 152 

Senile  Pruritus 154 

Varicose  Veins 156 

Secondary  Senile  Diseases 157 

Thrombosis  and  Embolism 157 

Senile  Gangrene 164 

Cardiac  Neuroses 166 

Palpitation 167 

Bradycardia 168 

Tachycardia 196 

Adams-Stokes  Disease ' 170 

Arrhythmia ' 171 

Angina  Pectoris 174 

Senile  Bronchitis 178 

Senile  Gastric  Catarrh 180 

Gastric  Neuroses 185 

Oesophageal  Neuroses 187 

Intestinal  Neuroses 188 

Cholelithiasis 188 

Senile  Metritis 191 

Cerebral  Anemia 193 

Alternating  Cerebral  Anemia  and  Hyperemia 193 

Cerebral  Softening 195 

Cerebral  Hemorrhage 198 

Senile  Neuritis 203 

Senile  Trifacial  Neuralgia 204 

Modified  Diseases  of  Old  Age 206 

Hay  Fever 207 

Senile  Asthma 208 

Pleurisy 209 

Pulmonary  Hyperemia 214 

Senile  Pneumonia 216 

Senile  Acute  Gastritis 223 

Simple  Chronic  Gastritis 225 

Senile  Diarrhea 226 

Senile  Cystitis 228 

Modified  Diseases  of  the  Skin 229 

Senile  Purpura 230 

Senile  Angioma 231 

Senile  Sebaceous  Naevi 232 

Senile  Keratoma 232 


CONTENTS  XI 

Pack 

Senile  Warts 2,, 

Rosacea 2,4 

Dermatides  with  Minor  Modifications 2^6 

Chronic  Ulcer      2 ., 

Neoplasms,  Benign 246 

Malignant 247 

Sarcoma 249 

Senile  Psychoses 251 

Modified  Psychoses 255 

Senile  Psychasthenia      257 

Senile  Neurasthenia 259 

Senile  Epilepsy 262 

Neuroses  of  the  Aged 264 

Insomnia      .  265 

Neuralgia 266 

Preferential  Diseases  of  Old  Age 268 

Carcinoma 268 

Oral 270 

Laryngeal 272 

Lung 273 

Pleura 273 

Mediastinum 274 

Oesophagus      274 

Stomach 275 

Intestines 277 

Liver 279 

Gall-bladder 280 

Pancreas 280 

Prostate 281 

Bladder 282 

Testicle 282 

Scrotum 283 

Penis 283 

Female  Genital  Organs      ■  283 

Breast 284 

Grawitz'  Cachexia 284 

Chronic  Laryngitis 285 

Chronic  Hypertrophic  Bronchial  Catarrh 286 

Pulmonary  Edema 288 

Pulmonary  Gangrene 290 

Pulmonary  Abscess 293 

Cardiac  Hypertrophy 294 

Cardiac  Dilatation •  296 

Fatty  Degeneration  of  the  Heart 300 

Fatty  Infiltration  of  the  Heart 30 1 

Valvular  Lesions 302 

Aortic  Regurgitation      3°6 

Aortic  Stenosis 3°9 

Mitral  Regurgitation 311 

Mitral  Stenosis 3*3 

Tricuspid  Regurgitation 3X4 


Xll  CONTENTS 

Page 

Combined  Valvular  Lesions 3*5 

Intestinal  Obstruction 32° 

Hemorrhoids 327 

Biliary  Obstruction 329 

Chronic  Interstitial  Nephritis 332 

Urolithiasis 337 

Senile  Metrorrhagia 342 

Chronic  Rheumatism 344 

Arthritis  Deformans       34^ 

Paget's  Disease 35° 

Gout 35i 

Diabetes  Mellitus 35$ 

Cerebral  Hyperemia       376 

Paralysis  Agitans 377 

Progressive  Bulbar  Paralysis 379 

Acute  Bulbar  Paralysis 381 

Pseudo  Bulbar  Paralysis 381 

Diseases  Uninfluenced  by  Age 382 

Infectious  Diseases 382 

Scarlatina 383 

Measles 384 

Diphtheria 384 

Whooping  Cough 386 

Mumps 386 

Malaria 386 

Yellow  Fever 387 

Dysentery 388 

Plague 390 

Cholera 39<> 

Variola 391 

Varioloid 392 

Typhoid 392 

Typhus 399 

Influenza 401 

Acute  Endocarditis 403 

Infectious  Pneumonia 405 

Tuberculosis 411 

Fibroid  Phthisis 412 

Miliary  Tuberculosis      415 

Relapsing  Fever      417 

Cerebrospinal  Meningitis 417 

Acute  Articular  Rheumatism 419 

Erysipelas 419 

Sepsis 421 

Gonorrhea 425 

Syphilis 426 

General  Anemia 429 

Pernicious  Anemia 432 

Leukemia 434 

Pseudoleukemic  Diseases 436 

Rhinitis 436 


CONTENTS  xiiJ 

Pack 
Diseases  of  the  Throat 8 

Laryngeal  Diseases 

Diseases  of  the  Thyroid  Gland 

Diseases  of  the  Adrenal  Glands   .    .  ... 

444 

Acute  Bronchitis ... 

444 

Bronchial  Stenosis ..^ 

Pericarditis ..- 

Gastric  Ulcer ..g 

Duodenal  Ulcer 4t-0 

Enteritis ^c0 

Diseases  of  the  Liver 41-6 

Diseases  of  the  Peritoneum 460 

Diseases  of  the  Pancreas 462 

Diseases  of  the  Spleen 463 

Diseases  of  the  Kidneys 464 

Hyperemia 464 

Nephritis      467 

Pyelitis 468 

Myalgia 468 

Myositis 470 

Meniere's  Symptom  Complex 471 

Osteomalacia 472 

Osteomyelitis       474 

Spinal  Diseases 474 

Cerebral  Diseases 475 

HYGIENE  AND  MEDICO-LEGAL  RELATIONS 

Home  Care  of  the  Aged 477 

Institutional  Care  of  the  Aged 485 

Medico-legal  Relations 497 

Marriage 503 

Sexual  Perversions 504 

Malingerers      506 

Index 511 


INTRODUCTION 


The  physiology,  pathology  and  therapy  of  early  age  have 
been  extensively  studied  and  discussed  in  our  country  these 
fifty  years.  Whatever  American  contributions  to  pediatrics 
there  were  before  1800,  could  easily  be  enumerated  on  a  few- 
pages  of  ' '  Janus,  1 900. "  After  that  time  there  were  a  few  books 
by  Dewces,  Eberle,  Stewart,  Condie  and  Meigs,  but  the  interest 
in  pediatrics  of  our  medical  profession  was  not  an  animated 
one  until  half  a  century  ago.  That  was  for  Europe  the  time  of 
the  epochmakers  Rilliet  and  Barthez,  Charles  West,  and  Karl 
Gerhardt.  With  us  pediatric  literature  and  the  taste  for  it, 
and  the  appreciation  of  its  necessity  and  dignity  have  deservedly 
grown  since.  Magazine  articles,  laboratory  and  bedside  reports, 
pamphlets  and  comprehensive  books — some  say  too  many — 
have  increased  to  such  an  extent  as  to  form  a  voluminous 
library.  Possibly,  however,  not  all  of  these  works,  mainly 
the  deluge  of  text  books  on  the  diseases  of  children,  are  ind;s- 
pensable,  many  may  have  been  merely  the  offsprings  of  the 
author's  autosuggestions.  Still,  even  they  demonstrate  the 
force  of  the  new  movement  and  the  extent  of  the  new  market. 
A  few  special  journals  have  also  proven  the  growing  interest  in 
pedology  which  was  exhibited  both  by  the  profession  and  the 
teachers  who  are  mostly  guided  by  the  suggestions  and  demands 
of  the  medical  public  as  represented  in  our  large  city,  state,  and 
national  associations.  This  tendency,  however,  has  fortunately 
not  succeeded  in  building  up  a  new  specialty  with  all  its  narrow- 
ing influences;  on  the  contrary,  it  has  broadened  the  horizon 
of  honest  students  and  made  better  general  practitioners  out  of 
those  whose  main  endeavors  were  diverted  to  understanding 
all  about  the  young.  At  the  same  time  those  whose  interests 
were  originally  confined  to  the  study  of  and  practice  among 
the  people  at  large,  added  to  their  intellectual  capital  by  acquir- 
ing the  results  of  specialistic  labors  in  pediatrics.  I  am  quite 
sure  that  the  pediatrist  cannot  succeed  in  his  practical  work 
without  being  a  close  student  of  nosology  in  general,  and  on  the 

xv 


xvi  INTRODUCTION 

other  hand,  that  the  "internist,"  the  general  practitioner  and 
physician  does  not,  without  being  at  the  same  time  a  pediatrist, 
reach  a  standard  by  which  he  may  be  of  real  use  either  at  the 
individual  bedside,  or  as  a  sanitarian  in  the  councils  oi  the  nation. 
The  world  is  entitled  to  demand  of  every  one  of  us  a  complete 
knowledge  of  and  profound  interest  in  the  physical  life  both  of 
the  young  and  the  old. 

Now  why  is  it  that  the  growing  interests  in  many  of  the 
branches  of  medical  science  and  practice  has  not  equally  been 
extended  to  the  diseases  of  old  age?  It  might  properly  be 
measured  by  the  literature  of  the  subject;  but  it  has  not  mani- 
fested itself  by  books  or  pamphlets  or  magazines,  nor  by  a 
specialistic  instruction  in  our  American  schools  of  medicine. 
Nor  has  any  of  our  great  and  influential  associations  insisted 
upon  the  appropriate  enlargement  of  the  medical  curricula  of 
our  teaching  institutions.  Our  American  literature  is  poverty 
stricken,  comparatively.  For  the  brilliant  labors  of  C.  S.  Minot 
in  part  published  in  the  Popular  Science  Monthly,  with  his 
"Problem  of  age,  growth  and  death"  (London,  1908)  has  not 
yet  fertilized  our  desert.  The  British  literature  to  which  we 
should  resort,  is  not  much  richer.  Day,  1849,  Mclaghlan,  1863, 
G.  M.  Humphrey,  1885,  G.  W.  Balfour,  1894,  Clifford  Albutt, 
1896  are  the  only  books  which  have  treated  of  old  age,  mono- 
graphically.  A  few  translations,  mainly  that  of  Charcot's 
lectures  on  senile  diseases  contained  in  the  new  Sydenham 
society's  publications  (vol.  95)  188 1  furnish  the  best  there  was 
of  what  now-a-days  is  considered  old  literature.  Finally  the 
eternally  young  Sir  Herman  Weber  has  given  us  in  two  editions 
of  "on  means  for  the  prolongation  of  life"  in  his  best  style 
his  philosophical  and  clinical  views  on  how  to  remain  young 
when  advanced  in  years,  and  Robert  Soundby  acknowledging 
the  defects  of  the  literature  of  his  country,  has  published  a 
very  competent  clinical  guide  ("Old  age,  its  care  and  treatment 
in  health  and  disease,"  London,  19 13). 

France  has  not  been  very  productive.  Still,  after  Gillette, 
185 1,  and  Reveille-Paris,  1853,  Charcot's  original  work  was  a 
great  achievement,  rich  and  fertile.  He  was  followed  by 
Demange  in  1886.  Boy-Teissier's  lectures  of  1895  and  G. 
Rauzier's  book  of  1909  are  valuable  and  influential  works. 
The  latter  seem   to   have   diverted   the    attention    of   young 


INTRODUCTION  xvii 

authors  to  the  subject  which  was  rather  neglected;  indeed 
during  the  last  few  years  more  than  a  dozen  Paris  inaugural 
theses  have  been  published;  they  treat  monographically  of  old 
or  senile  organs. 

Germany  has  proven  its  supremacy  as  the  modern  leader 
in  medical  science  through  its  contributions  to  what  Doctor 
Nascher  proposes  to  teach  under  the  heading  of  geriatrics.  After 
Fischer's  Tractatus  de  senio,  1766,  comprehensive  treatises  have 
been  furnished  by  Canstatt,  1839;  Geist,  i860;  Mettenheimer, 
1863;  F.  W.  Muller,  1863;  Seidel,  1889;  Muhlmann,  1900; 
F.  Friedmann,  1902;  Schwalbe,  1909  Lindheim,  1909  and  Arne 
Faber,  19 12.  Avast  number  of  German  monographs,  clinical, 
pathological,  histological  and  therapeutical,  have  added  to  our 
knowledge.  Aschoff 's  many  studies  published  during  the  last  few 
years  will  long  be  our  guides  in  the  appreciation  of  the  dignity 
and  import  of  the  advancing  changes  of  the  blood-vessels. 

Dr.  Nascher  has  undertaken  to  write,  what  for  our  country 
seems  to  be  the  first  modern  comprehensive  book  on  the  normal 
and  the  morbid  changes  of  old  age.  He  has  honored  me  by 
permitting  me  to  accompany  it  with  this  introduction  to  the  med- 
ical public.  This  work  has  been  suggested  to  him  by  his  scien- 
tific interest,  continued  study  and  humane  sympathy.  He  does 
not  mean  to  take  the  sufferings  of  old  age  and  early  death  for 
granted,  and  for  welcome  dispensations  of  providence.  That 
may  be  the  point  of  view  sufficient  for  the  statistician,  while  the 
individual,  beyond  the  threatened  premature  decay,  has  a 
justifiable  claim  to  comparative  health,  persistent  comfort,  and 
uninterrupted  efficiency.  These  are  the  great  assets  of  the  indi- 
vidual who  looks  for  competency  and  enjoyment,  and  of  the 
human  society  which  has  a  right  to  demand  cooperative  services 
from  all.  For  premature  incompetency  and  premature  death 
mean  private  and  collective  bereavement.  It  is  the  domain  of 
the  physician  for  whom  this  book  is  written  to  combat  them.  If 
it  be  correct  that  sclerosis  and  atheromatosis  and  cell  atrophy  and 
malignant  proliferations  are  natural  results  of  histological  changes 
resulting  in  vital  retrogression  or  malignant  degeneration,  and 
in  sufferings  and  dangers,  they  can  and  should  be  delayed  and 
rendered  less  formidable  or  even  innocuous  by  the  very  props  and 
staffs  of  childhood  and  adult  life,  viz.,  hygiene,  diet,  drugs  and 
surgical  aids. 


xviii  INTRODUCTION 

The  study  of  advanced  age  will  enhance  the  competency  of 
the  physician  to  the  same  degree  to  which  it  was  advanced  by 
the  closer  knowledge  of  the  physiology  and  pathology  of  the 
infant  and  child.  With  this  difference:  the  baby  offers  but  few 
difficulties  in  arriving  at  a  diagnosis.  His  diseases  are  simple. 
He  has  only  one  at  a  time.  Complications  are  infrequent,  but 
the  perplexities  grow  from  decade  to  decade.  For  there  are  only 
few  diseases  that  leave  no  remnants.  The  recovery  from  every 
new  disease  contracted  at  any  period  of  life  is  handicapped  by 
the  tissue  changes  left  behind  from  previous  accidents  or  ail- 
ments. There  are  few  persons  of  advanced  years  without  a 
permanent  blemish — one  or  many — which  make  the  diagnosis  of 
any  additional  illness  or  morbid  condition  more  difficult,  treat- 
ment more  uncertain,  and  complete  recovery  more  doubtful. 
That  is  why  I  imagine  that  Doctor  Nascher  by  offering  the  prac- 
titioner of  medicine  this  book,  will  render  him  a  meritorious 
service. 

#     1  Mfix 


GERIATRICS 


CHILDHOOD  AND  OLD  AGE 

Senility  is  often  called  Second  Childhood.  A  comparison 
of  the  organism  in  childhood  with  the  organism  in  old  age  will 
show  that  there  is  not  an  organ  or  tissue,  not  a  function,  mental 
or  physical,  identical  at  the  two  periods  of  life.  Vitality, 
metabolism,  even  instinct  differ.  The  process  of  senescence 
is  progressive,  not  retrogressive,  there  is  no  reversal  in  the  order 
of  development  and  not  a  single  tissue  reverts  to  an  earlier  type. 

If  we  accept  the  theory  of  tissue  cell  evolution  as  the  funda- 
mental cause  of  ageing,  we  must  seek  the  fundamental  difference 
between  childhood  and  old  age  in  the  cells  at  the  two  periods  of 
life.  There  are  however  profound  differences  in  the  organs  as 
entities  and  in  the  organism  as  a  whole.  /While  the  gross 
differences  are  obvious  or  demonstrable,  we  have  but  slight  knowl- 
edge of  the  changes  in  the  cell.  It  is  probable,  however,  that 
some  of  the  cell  and  tissue  changes  are  not  inherent  but  are 
caused  by  some  change  in  nutrition.  We  have  not  yet  discov- 
ered any  change  in  the  blood  at  the  two  periods  except  in  the 
proportion  of  salts  and  in  viscosity,  although  the  spleen  and  bone 
marrow  are  greatly  altered  in  advanced  age.  J 

It  would  carry  us  beyond  the  scope  of  this  work  to  discuss 
the  kinship  between  chemical  and  physical  affinities  such  as 
occur  in  simple  substances  like  potassium  for  oxygen  and  its 
oxide  for  water,  and  the  elective  affinities  of  complex  substances 
like  protoplasm  for  the  complex  substances  they  require  as 
pabulum.  As  a  result  of  the  fulfilment  of  the  elective  affinities 
in  the  organism  there  is  going  on  a  constant  change  of  chemical 
combination,  cyclic,  uniform,  unchanging  in  character,  the  like 
pabulum  constituents  being  converted  into  like  substances 
forming  body  or  waste,  f  Neither  chemist,  cytologist  nor  physiolo- 
gist has  been  able  to  explain  the  biochemical  changes  in  the  cell 
or  the  metabolic  changes  in  the  organism  or  demonstrate  order 
in  them  by  formula  or  law. )   Any  school  boy  can  show  by  sym- 

i 


2  PHYSIOLOGICAL   OLD   AGE 

bols  how  amorphous  phosphorus  will  combine  with  calcium  and 
oxygen  to  form  the  tribasic  phosphate  of  calcium,  but  no  scien- 
tist has  yet  explained  how  this  combination  is  brought  about  in 
the  body  since  this  form  of  phosphorus  is  insoluble,  even  in  serum 
and  the  tricalcic  phosphate,  in  which  form  it  is  eliminated,  is 
insoluble  in  water  and  but  slightly  soluble  in  weak  acids.  Shall 
we  say  that  living  blood  has  solvent  powers  not  possessed  by  any 
other  solvent?  How  can  we  explain  the  normally  increased 
retention  of  lime  in  the  aged  and  its  deposit  in  locations  in  which 
it  is  never  found  in  early  life,  except  in  disease?  We  must 
assume  that  the  early  cells,  which  show  intense  greed  for  pabu- 
lum, will  not  take  up  more  lime  than  the  organism  requires  for 
healthy  growth  and  they  may  take  up  less,  causing  rickets  and 
similar  conditions  of  lime  deficiency,  while  the  aged  cells,  in 
spite  of  their  lessened  appetite,  show  a  greater  elective  affinity 
for  lime.  We  must  also  assume  that  the  blood  has  a  greater 
affinity  for  lime  while  the  metabolic  processes  are  so  altered  that 
less  is  eliminated.  Minot  has  shown  that  there  is  an  increase  in 
protoplasm  in  aged  cells  but  this  alone  would  hardly  explain  the 
profound  differences  in  cell  activities  at  different  periods  of  life. 
It  is  probable  that  there  is  a  difference  in  the  character  of  the 
protoplasm  itself  and  perhaps  in  the  nuclear  constituents, 
since  recent  investigations  have  demonstrated  dissimilarities  in 
the  chemical  composition  of  the  proteids  of  different  cells,  which 
were  supposed  to  be  identical.  Greater  refinement  in  chemical 
analysis  and  increased  microscopic  power  will  undoubtedly 
reveal  chemical  differences  and  organic  changes  which  will 
clear  up  these  problems. 

At  the  present  moment  there  is  but  one  rational  assumption 
by  which  we  can  explain  the  progressive  changes  in  the  properties 
of  cells  and  the  tissues  which  they  form,  (it  is,  that  in  the  con- 
stant waste  and  repair  of  tissue  the  newer  cells  differ  from  the 
earlier  ones,  that  in  advanced  life  none  of  the  early  cells  are  left 
(except  brain  cells) ,  that  the  aged  individual  is  in  fact  an  entirely 
different  individual  from  the  one  who  was  formed  from  the  ances- 
tors of  the  late  cells.  The  only  connecting  link  between  the 
child  organism  and  the  senile  organism  is  the  brain,  as  it  is 
believed  that  brain  cells  do  not  regenerate  themselves,  that  the 
old  cells  were  all  present  at  birth  though  changed  in  structure  and 
perhaps   in   composition   in   the   process   of   development   and 


CHILDHOOD   AND   OLD   AGE  o 

senescence.  There  is  still  the  same  personality,  modified  by- 
intelligence,  education  and  the  acquisition  and  suppression  of 
traits.  Continuity  of  activity  is  maintained  by  retention  of 
sentience  in  the  original  cells,  instead  of  by  transmission  from 
generation  to  generation  of  cells  as  in  other  tissues.  Like  the 
old  vessel  which  has  been  repeatedly  repaired  until  not  a  splinter 
of  the  original  timbers  is  left,  the  individuality  and  the  name 
remain.  / 

Growth  in  youth  depends  primarily  upon  nutrition.  The 
underfed  child  is  also  underdeveloped  and  no  amount  of  over- 
feeding after  the  developmental  period  will  increase  the  growth 
of  undeveloped  tissues.  When  well  fed  children  are  under- 
developed there  is  usually  a  dyscrasia  causing  impaired  general 
metabolism,  or  there  may  be  deficient  digestion  and  assimilation 
or  else  general  cell  sluggishness,  usually  a  transmitted  quality. 
Whatever  the  cause  may  be  the  whole  physical  organism  suffers 
but  mentality  is  rarely  impaired.  In  the  atrophy  of  advanced 
life  there  is  no  uniformity  in  cause,  extent  or  mode  of  procedure 
and  like  tissues  may  undergo  different  forms  of  degeneration  in 
different  parts  of  the  body.  Some  organs  and  tissues  degenerate 
earlier  and  more  rapidly  than  others  but  with  few  exceptions,  as 
the  thymus  gland  and  the  female  generative  organs,  there  is  no 
time  or  regularity  in  the  order  of  the  senile  degenerations.  Inac- 
tive striped  muscular  fiber  degenerates  early  and  undergoes 
fatty  infiltration  and  degeneration.  Active  striped  muscular 
fiber  does  not  degenerate  until  it  has  reached  its  maximum 
growth  after  which  the  extent  of  degeneration  depends  upon  the 
activity  or  work  it  is  called  upon  to  perform.  If  it  is  not  exces- 
sively employed  it  degenerates  late  and  then  atrophies  with  loss 
of  power  proportionate  to  the  waste  of  tissue.  If  excessively 
employed,  there  is  loss  of  tonicity  and  a  change  in  the  character 
of  the  fiber,  usually  a  fatty  degeneration.  When  healthy  tissue 
normally  employed  atrophies  we  look  for  a  nutritional  fault 
and  we  generally  find  an  impaired  blood-supply.  In  old  age  we 
have  altered  cells  and  supposedly  altered  blood.  Do  these  aged 
cells  require  a  different  pabulum  from  the  earlier  cells?  Does 
the  blood  in  the  aged  carry  insufficient  cell  nutriment  or  are  the 
nutritional  constituents  so  changed  as  to  be  unsuitable,  or  does  it 
carry  constituents  inimical  to  cell  life  ?  Transfusion  of  the  blood 
of  a  young  person  into  an  old  person  apparently  does  not  inhibit 


PHYSIOLOGICAL    OLD   AGE 


senile  changes  nor  does  the  blood  of  an  old  individual  into  a 
younger  one  induce  such  changes.  Further  experimentation 
along  these  lines  is  necessary  to  determine  the  influence  of  the 
blood  at  different  ages  upon  young  and  old  cells.  (W.  T.  Gibb 
suggested  to  the  author  the  transfusion  of  blood  from  an  old 
member  of  a  family  possessing  hereditary  longevity  into  a  young 
member  of  a  short  lived  family  for  the  purpose  of  promoting 

longevity.) 

There  are  however  other  causes  for  senile  tissue  atrophy 
than  the  fundamental  changes  in  the  cells  and  the  probable 
change  in  the  blood.  Connective-tissue  proliferation  may  com- 
press tissue  cells  as  in  the  liver,  bands  of  connective  tissue  may 
compress  blood-vessels  and  lessen  the  blood-supply  as  occurs  in 
the  spleen,  or  the  swelling  of  endothelial  cells  may  diminish  the 
caliber  of  vessels  as  occurs  in  the  vasa  vasorum. 

We  have  still  to  consider  the  differences  in  vitality,  metabo- 
lism and  mentality  in  the  two  extremes  of  life.  Under  vital- 
ity will  be  included  irritability  or  the  property  of  responding  to 
external  stimuli,  sentience  or  automatism  independent  of  exter- 
nal stimulus,  vital  energy  and  vital  resistance.  (The  term  sen- 
tience is  used  here  to  designate  the  property  of  originating  action 
independent  of  irritation  or  purpose.  This  would  include  in- 
stinctive acts  and  acts  performed  unconsciously  though  such  are 
not  usually  included  in  this  term.)  While  these  properties  are 
intimately  related  they  will  be  dealt  with  separately. 

Irritability  is  pronounced  in  childhood  and  weakened  in  old 
age.  It  requires  a  much  greater  stimulus  to  the  aged  sense  or- 
gans to  rouse  sense  perception  and  the  responses  are  slower  than 
in  earlier  life,  and  the  same  applies  to  tissues  where  the  senses  are 
not  involved.  The  ciliated  epithelium  for  example  is  much  more 
sensitive  in  the  child  and  a  slight  irritation  to  the  cells  is  followed 
by  stimulation  of  the  glands  in  the  underlying  mucous  mem- 
brane. For  this  reason  the  mucus  expectorated  by  the  child  is 
usually  clear  while  the  mucus  expectorated  by  the  aged  individ- 
ual is  usually  dark  from  dust  particles  which  had  accumulated 
on  the  membrane  without  causing  enough  irritation  to  the  cilia- 
ted epithelium  to  induce  immediate  coughing  to  dislodge  them. 
Reflex  action  in  the  young  follows  initial  irritation  rapidly  and 
instinctive  acts  are  readily  aroused  upon  slight  stimulus  while 
in  the  aged  reflex  action  is  slowed  and  weakened  and  instinctive 


CHILDHOOD    AND    OLD   AGE  r 

acts  are  rare.  Evidences  of  diminished  irritability  in  the  aged 
are  obvious  in  almost  every  act  they  perform.  We  must  remem- 
ber however  that  slowed  responses  may  also  be  due  to  weakened 
mentality,  a  longer  time  being  required  to  translate  the  irritation 
and  determine  the  response. 

Sentience  is  active  in  the  young,  weak  in  the  aged.  The 
regulating  centers  in  the  aged  are  weakened  and  while  some  are 
easily  disturbed  others  require  a  powerful  stimulus  to  cause 
any  change  in  their  activity.  The  activity  of  the  heat  regulat- 
ing center  is  lessened  and  there  is  a  general  lower  temperature 
with  a  normal  range  of  about  two  degrees  in  the  course  of  the 
day.  In  old  age  some  profound  influence  is  necessary  to  raise 
the  temperature  three  degrees  while  in  childhood  with  a  normal 
range  of  a  degree  or  less,  slight  influences  will  stimulate  this  center 
and  cause  a  rapid  rise  of  several  degrees  with  an  equally  rapid 
fall  to  normal.  The  heart-regulating  centers  are  easily  disturbed 
in  the  aged,  the  respiratory  center  can  stand  but  little  disturb- 
ance while  the  vasomotor  center  is  in  a  constant  state  of  unstable 
activity.  In  the  young  functional  disturbances  not  due  to  ana- 
tomic changes  are  quickly  regulated  and  normal  functions  are 
restored  without  serious  impairment  of  the  organs;  aged  tissues 
cannot  readily  accommodate  themselves  to  functional  changes  and 
they  quickly  degenerate.  Automatic  activity  such  as  respira- 
tion, heart  action,  peristalsis,  glandular  action,  and  voluntary 
sentient  acts  as  deglutition  without  food  irritation,  the  control  of 
the  sphincters,  the  swinging  of  the  arms  when  walking,  are  all 
performed  less  energetically  in  old  age.  Early  life  is  marked 
by  cellular  activity;  age,  by  cell  sluggishness. 

Vital  energy  gradually  diminishes  with  age  except  during 
the  menopause,  critical  period  of  the  male  and  the  senile  climac- 
teric. These  periods  are  marked  by  increased  mental,  physical 
and  metabolic  activity  and  are  followed  by  rapidly  diminishing 
activity  and  energy.  In  youth  there  is  a  wide  margin  between 
normal  functional  activity  and  the  limit  of  functional  capacity. 
In  advanced  age  the  normal  functional  activity  is  diminished 
but  the  limit  of  functional  capacity  is  lowered  much  faster  and 
the  margin  between  the  two  is  gradually  lessened.  Activity 
is  maintained  by  vital  energy,  but  when  carried  to  the  limit  of 
functional  capacity,  further  activity  causes  exhaustion  or  paraly- 
sis or,  in  the  case  of  blood-vessels,  rupture.     In  the  young  person, 


6  PHYSIOLOGICAL   OLD    AGE 

after  running,  the  heart  will  beat  faster,  respiration  is  more 
rapid  and  all  the  organs  and  tissues  show  the  effect  of  greatly- 
accelerated  circulation.  The  young  person  is  forced  to  stop 
through  muscle  exhaustion,  complete  recuperation  following  rest. 
Only  in  case  of  heart  disease  is  there  any  danger  from  heart 
exhaustion.  In  the  aged  the  limit  of  functional  capacity  is 
reached  before  muscle  exhaustion  sets  in  and  death  may  occur 
from  heart  exhaustion,  respiratory  paralysis  or  rupture  of  an 
atheromatous  artery.  This  does  not  show  diminished  vital 
energy  but  diminished  functional  capacity.  Diminished  vital 
energy  is  shown  by  the  greater  effort  or  impulse  required  to 
perform  acts.  Acts  now  require  a  sensible  effort  and  a  conscious 
purpose  which  were  formerly  performed  unconsciously  or  with- 
out any  conscious  mental  or  physical  effort,  as  the  regulation 
of  the  step  when  walking  or  the  arm  movement  when  conveying 
food  to  the  mouth,  swallowing,  recalling  a  familiar  name  or 
simple  relations  between  things,  listening,  seeing,  crossing  the 
legs,  etc.  The  child  in  play  runs  to  hide.  The  impulse  to  run 
is  sudden  and  instantaneous  and  no  thought  is  given  to  the 
movement  of  the  legs  in  the  act  of  running.  The  energy  ex- 
pended is  so  slight  as  to  be  unnoticed  unless  fatigue,  palpitation 
or  dyspnea  sets  in.  The  old  man  needs  a  conscious  impulse, 
a  mental  push,  to  start  running  and  his  thoughts  are  on  the 
act  instead  of  its  purpose.  He  may  walk  absent  mindedly  as 
this  requires  little  effort  or  energy  but  he  will  not  run  absent 
mindedly. 

Vital  energy  is  sometimes  divided  into  three  forces,  bath- 
mism  or  growth  force,  neurism  or  nerve-force  and  phrenism  or 
brain  force.  In  childhood  the  growth  force  is  exerted  in  two 
directions,  or  rather  with  two  distinct  purposes,  accumulation 
of  tissue  and  differentiation  of  the  sexes.  In  old  age  there  is 
still  growth  of  tissue  but  the  new  tissue  does  not  fully  compen- 
sate for  the  waste  except  in  a  few  tissues.  This  growth  force  is 
now  mainly  exerted  toward  the  approximation  of  the  sexes  and 
in  old  age  they  approach  a  neutral  type.  This  is  more  pronounced 
in  the  virilescence  of  the  female.  In  the  female  there  is  usually 
a  growth  of  hair  upon  the  face,  while  the  hair  on  the  face  of  the 
male  becomes  thin.  Her  voice  becomes  lower,  his  becomes 
higher  in  pitch.  The  changes  in  the  male  pelvis  and  in  the  neck 
of  the  femur  produce  a  greater  width  between  the  crests  of  the 


CHILDHOOD   AND   OLD   AGE  7 

ilia,  and  the  proportion  between  width  at  the  hips  and  length  of 
the  spinal  column  is  greater  in  the  aged  man  than  in  the  younger 
male  and  may  equal  the  proportion  found  in  the  female.  The 
pelvis  of  the  female  infant  is  of  the  male  type  while  the  pelvis 
of  the  aged  male  approaches  the  female  type.  The  thoracic 
changes  are  the  same  in  both  sexes  and  in  the  female  the  breasts 
shrivel.  The  changes  in  the  lower  maxilla  in  advanced  age  give 
to  both  the  weazened  face  and  there  is  often  the  same  facial 
expression.  We  frequently  see  photographs  of  aged  individuals 
in  which  the  face  alone  gives  as  little  indication  of  the  sex  as  the 
face  of  the  infant.  The  diminution  in  nerve-force  needs  no  dis- 
cussion as  it  is  evident  in  every  act  of  the  aged  individual.  The 
alteration  in  brain  force  will  be  taken  up  under  mentality. 

Vital  resistance  or  the  opposition  of  the  living  organism  to 
deleterious  influences  differs  at  the  two  periods  of  life.  The 
young  are  much  more  susceptible  to  infectious  diseases  than  the 
aged  and  the  eruptive  diseases  of  early  life  rarely  or  never  occur 
in  the  aged  while  other  bacterial  diseases  occurring  in  the  aged 
are  milder.  Various  explanations  have  been  given  for  this 
phenomenon,  such  as  poor  soil,  lower  temperature,  more 
opsonins,  more  active  leucocytosis,  etc.  We -are  again  confronted 
by  the  question,  is  the  blood  of  the  aged  essentially  different 
from  the  blood  of  the  child  ?  Is  there  any  difference  in  the  char- 
acter and  activity  of  the  cells  ? 

The  child  can  stand  changes  in  temperature,  atmospheric 
pressure,  environment  and  mode  of  life  better  than  the  aged. 
Dietary  changes  affect  the  child  more  powerfully.  While  the 
child  is  readily  affected  by  deleterious  influences  and  inflam- 
matory conditions  are  easily  produced,  the  young  organism  can 
accommodate  itself  to  such  influences;  and  if  disease  occurs  vital 
energy  maintains  functional  activity  until  the  organs  or  tissues 
involved  are  restored  to  their  normal  condition.  In  the  aged 
inflammatory  conditions  are  infrequent,  when  disease  occurs 
the  healthy  senile  organs  cannot  readily  accommodate  them- 
selves to  functional  changes  in  diseased  organs,  the  functions 
are  maintained  with  difficulty  owing  to  diminished  vital  energy 
and  little  or  no  reserve  energy,  and  tissues  and  their  functions 
remain  impaired  or  very  slowly  recover  to  their  normal  senile 
state. 

Metabolic   activity   is   altered   in   old   age   and   markedly 


8  PHYSIOLOGICAL    OLD   AGE 

different  from  metabolic  activity  in  childhood.  In  childhood 
there  is  active  destructive  and  constructive  metabolism,  the 
regeneration  being  in  excess  of  the  waste.  Stohr  says  ' '  a  femur 
of  a  three  year  old  child  contains  scarcely  any  of  the  osseous 
tissue  present  at  birth."  In  old  age  metabolic  activity  is  les- 
sened, the  anabolic  processes  being  less  active  than  the  catabolic 
processes.  Insufficient  repair  is  found  more  especially  in  the 
higher  order  of  tissues,  the  brain,  marrow,  spleen  and  muscle, 
tissues  which  require  a  plentiful  supply  of  blood  for  their  nutri- 
tion, while  in  the  lower  order  of  tissues  like  connective  tissue, 
fat  and  hair  there  may  be  increased  growth.  Assimilation  is 
altered  in  advanced  age,  many  substances  which  in  earlier  life 
are  retained  and  converted  being  now  rejected  and  thrown  out 
in  the  feces.  The  intestinal  decomposition  products  are  in- 
creased, the  total  amount  of  urea  and  uric  acid  eliminated  is 
greatly  diminished,  only  about  half  of  the  amount  of  C02 
exhaled  in  early  maturity  is  given  off  in  senility,  while  the 
elimination  of  waste  by  the  skin  is  very  small.  Abnormal 
fatty  acids  are  produced  and  eliminated  as  fetid  perspiration. 
Indican  is  always  present  in  the  urine.  A  smaller  amount  of 
food  is  required  by  the  system  in  old  age  and  the  excess  of  food 
is  thrown  off  in  a  lienteric  diarrhea.  The  water  content  of  the 
blood  and  tissues  is  diminished  but  increased  liquid  ingesta 
increases  the  urine  output  without  relieving  the  dryness  of  the 
tissues  or  diminishing  the  viscosity  of  the  blood.  Salines  which 
increase  the  fluidity  of  the  blood  are  readily  absorbed  but  are 
rapidly  eliminated,  while  calcium  salts  which  increase  the  vis- 
cosity of  the  blood  are  retained.  The  natural  adaptation  of 
tastes,  wants  and  supply  to  the  needs  of  the  organism  is  beauti- 
fully illustrated  in  the  aged.  There  is  diminished  activity  and 
lessened  need  for  carbohydrates  and  there  is  a  distaste  for 
sweets.  The  bile  is  diminished  and  there  is  a  distaste  for  fats. 
With  the  falling  out  of  the  teeth  there  is  a  dislike  for  meat, 
vvhich  must  be  masticated.  The  amount  of  hydrochloric  acid  in 
the  stomach  is  diminished  and  the  aged  individual  craves  for 
sour  and  salty  things  while  insipid  foods,  which  are  usually 
alkaline,  are  rejected.  If,  through  the  trickery  of  the  cook  or 
the  perversion  of  taste,  inappropriate  or  excessive  food  is  taken, 
it  is  eliminated  by  the  bowels  unchanged  or  but  slightly  con- 
verted.    The  child  usually  vomits  inappropriate  food  but  food 


CHILDHOOD    AND    OLD   AGE  g 

in  excess  is  retained  and  stored.  This  is  especially  marked 
when  sweets  are  taken  in  excess,  and  accounts  for  the  chubby 
figures  of  children  and  young  women  in  places  where  much  sweets 
are  used.  The  fancied  similarity  in  the  mentality  of  childhood 
and  old  age  gives  rise  to  the  belief  that  senility  is  second  child- 
hood. Only  in  the  complete  absence  of  intelligence  of  the  new- 
born infant  and  the  absolute  dement  is  there  any  resemblance 
in  their  mentality.  Even  then  the  child  performs  instinctive 
acts  and  gives  evidence  of  sensations  as  pain,  hunger  and  dis- 
agreeable impressions  which  are  absent  in  the  complete  dement. 
The  child  is  guided  by  ancestral  knowledge  or  instinct  but  such 
knowledge  has  virtually  disappeared  in  old  age.  Whatever 
acts  the  aged  individual  performs  are  the  result  of  a  conscious 
purpose  and  reason  or  else  of  habit  or  irritation.  Sense  percep- 
tion is  strong  in  childhood,  weak  in  old  age.  This  weakness  is 
due  partly  to  impairment  of  the  sense  organs,  partly  to  weakened 
mental  perception.  Memory  is  strongly  developed  in  the  child; 
it  receives  impressions,  stores  them  and  recalls  them  at  will  as 
mental  pictures,  sounds  or  other  sensations,  without  apparent 
effort.  In  the  aged  only  powerful  impressions  or  those  directly 
affecting  the  individual  are  retained.  A  sensible  effort  must  be 
made  to  recall  earlier  impressions  although  very  early  impres- 
sions will  reappear  without  effort  or  design  and  the  aged  person 
boasts  of  his  wonderful  memory.  Reason  is  a  late  acquisition  of 
the  child  and  persists  late  in  the  aged.  The  child's  mind  is 
analytical;  it  wants  to  know  why,  and  it  will  take  apart,  destroy, 
question.  The  senile  mind  is  synthetical ;  it  wants  to  know  how, 
to  combine,  to  construct  and  to  restore.  In  rare  cases  children 
will  construct  and  aged  persons  will  analyze  and  destroy.  We 
call  these  geniuses.  In  other  cases  individuals  will  perform 
remarkable  constructive  work  at  an  advanced  age.  Here  we 
will  usually  find  all  mental  efforts  directed  into  one  channel 
and  the  particular  work  stands  out  prominently  while  in  every 
other  direction  the  mental  faculties  are  deficient.  There  are 
differences  in  judgment,  imagination,  the  ethical  sense,  the  es- 
thetic sense,  sentiment  and  other  mental  traits  and  characteris- 
tics between  childhood  and  old  age  but  these  differ  so  widely  in 
individuals  of  the  same  age  that  we  cannot  make  a  broad 
distinction  at  the  two  periods  of  life.  The  same  applies  to  the 
will,  although  the  aged  generally  will  follow  the  lines  of  least 


IO  PHYSIOLOGICAL   OLD   AGE 

resistance,  become  subjective  and  submit  choice  and  resolution 
to  the  will  of  others.  The  child  in  its  general  conception  of  life 
and  the  world  gives  no  thought  to  its  somatic  self ;  the  aged  gradu- 
ally constricts  his  conception  of  life  and  the  world  until  it  is 
centered  upon  himself;  his  interests  are  all  concentrated  in  the 
preservation  of  his  life.  While  the  fundamental  difference 
between  the  young  and  the  old  organism  must  be  sought  in  some 
essential  change  in  the  character  of  the  cell,  the  fundamental 
difference  between  childhood  and  old  age  can  be  summed  up  in 
this.     Youth  wants  to  know;  age  wants  to  be. 


PART  I 
PHYSIOLOGICAL  OLD  AGE 


THE  SENILE  STATE 

We  cannot  deal  understandingly  with  senile  diseases  if  we 
do  not  understand  the  senile  organism.  We  cannot  under- 
stand the  senile  organism  unless  we  study  it  as  a  physiological 
entity  entirely  apart  from  maturity.  The  physician  must  look 
upon  old  age  as  he  does  upon  childhood.  His  conception  of  the 
child  is  not  of  an  adult  with  undeveloped  organs  and  tissues,  nor 
does  he  deal  with  the  diseases  of  that  period  of  life  as  though 
they  were  diseases  of  maturity  complicated  with  immature 
development.  A  pulse  of  120  in  an  infant  does  not  mean 
tachycardia  nor  does  limited  reasoning  power  stamp  the  infant 
as  an  idiot.  These  conditions  are  natural  and  normal  at  that 
period  of  life  although  they  are  unnatural,  abnormal  and 
pathological  in  maturity.  We  must  take  a  similar  view  of 
senility.  We  must  look  upon  the  degenerations,  the  atrophies, 
hypertrophies  and  all  the  changes  in  form  and  character,  that 
are  due  to  the  process  of  involution,  as  natural,  normal  and 
physiological.  The  brittleness  of  bone  in  the  aged,  due  to  the 
waste  of  organic  matter  and  the  proportionate  excess  of  lime 
salts,  is  as  natural  as  is  the  softness  and  elasticity  of  bone  in 
childhood  when  there  is  still  an  insufficiency  of  lime  salts. 
Senile  debility  is  no  more  a  pathological  condition  than  is  the 
weakness  of  the  infant,  senile  contracted  kidney  is  not  Bright's 
disease  although  it  resembles  interstitial  nephritis ;  the  hardened, 
contracted  capsular  ligament  is  not  a  disease  of  metabolism 
although  the  stiffness  occasioned  thereby  and  the  pain  on  motion 
resemble  rheumatism.  The  irregularity  in  the  order  and  the 
wide  variations  in  time  and  extent  of  the  senile  changes  in  dif- 
ferent individuals  make  it  impossible  to  establish  a  norm  or 
standard  for  these  changes.  Neither  can  we  determine  the 
extent  of  the  senile  process  of  involution,  from  the  individual. 
It  is  not  unusual  to  find  an  individual  presenting  the  appearance 
of  extreme  decrepitude  without  marked  changes  in  the  internal 

11 


12  PHYSIOLOGICAL   OLD   AGE 

organs  and,  on  the  other  hand,  we  sometimes  find  apparently 
robust  individuals  with  early  signs  of  arteriosclerosis,  cardiac 
hypertrophy,  and  the  whole  train  of  changes  that  arise  from 
defective  nutrition  and  elimination  of  waste,  following  senile 
changes  in  the  circulatory  system.  Another  difficulty  in  the 
way  of  determining  a  norm  or  standard  of  senile  types  is  the 
impossibility  of  fixing  averages  such  as  serve  for  determining 
standards  in  maturity.  In  maturity  the  anatomical  condition 
and  the  physiological  function  generally  bear  a  definite  relation 
to  each  other.  In  advanced  age  we  frequently  find  degenerative 
changes  without  marked  noticeable  change  in  function;  indeed, 
we  may  find  the  changes  due  to  age  occur  in  early  maturity 
while  functional  activity  may  increase.  The  brain  reaches  its 
maximum  weight  about  the  thirtieth  year  after  which  there  is 
a  gradual  loss  of  weight,  yet  the  maximum  mental  capacity  is 
generally  reached  about  the  fiftieth  year  or  later.  The  lungs 
reach  the  maximum  respiratory  capacity  about  the  thirtieth 
year,  and  a  diminution  from  this  maximum  capacity  has  been 
demonstrated  before  the  fortieth  year  while  the  earliest  symp- 
tom of  impaired  respiration,  dyspnea,  does  not  usually  manifest 
itself  before  the  middle  of  the  sixth  decade  of  life.  Since  we 
are  unable  under  these  circumstances  to  establish  a  standard 
based  upon  either  age,  or  extent  or  character  of  morphological 
changes  it  will  be  necessary  to  use  extreme  types  for  the  purpose 
of  description.  We  must  remember,  however,  that  even  such 
types  may  be  normally  exceeded,  while  under  some  circumstances 
slight  deviations  from  the  norm  of  maturity  may  be  patho- 
logical. We  also  find  occasionally  a  pathological  condition  which 
has  existed  for  so  long  a  time  that  it  has  become  normal  to  the 
individual.     Such  cases  will  receive  no  further  consideration. 

The  obvious  characteristics  of  senility  are  evidenced  in  the 
appearance,  attitude,  gait,  mentality  and  the  tout  ensemble  of 
mental  and  physical  decay.  The  appearance  of  the  senile 
individual  is  repellent  both  to  the  esthetic  sense  and  to  the 
sense  of  independence,  that  sense  or  mental  attitude  that  the 
human  race  holds  toward  the  self-reliant  and  self-dependent. 
It  is  not  within  the  scope  of  this  work  to  discuss  the  psychonomy 
of  the  emotions;  this  much  is  however  certain:  While  the 
dependence  of  the  child  arouses  sympathy,  in  the  aged  the 
repugnance  aroused  by  the  disagreeable  facial  aspect  and  the 


THE    SENILE    STATE 


13 


idea  of  economic  worthlessness  destroys  the  sympathy  we 
bestow  upon  the  child  and  instills  a  spirit  of  irritability  if  not 
positive  enmity  against  the  helplessness  of  the  aged.  We 
find  herein  one  of  the  causes  for  the  general  neglect  of  the  aged, 
where  this  spirit  is  not  overcome  by  a  spirit  of  reverence.  The 
mental  depression  and  the  lack  of  interest  in  things  beyond  the 
ego  of  the  aged  individual  contribute  to  the  general  feeling  of 
repulsion  and  all  these  factors  accentuate  the  disagreeable 
tout  ensemble  of  old  age.  The  countenance  is  either  expres- 
sionless, indicating  mental  weakness,  or  there  is  an  apathetic 
moroseness  indicative  of  helpless  resignation,  or  else  there  is 
the  anxious  look  associated  with  a  haunting  fear.  The  skin  is 
dry,  lusterless,  darker  than  in  maturity,  often  pigmented,  loose 
and  thin,  showing  varicosed  veins  and  tortuous  arteries  under- 
neath. In  some  localities  the  skin  lies  in  folds  producing  coarse 
and  fine  wrinkles.  This  is  due  partly  to  the  looseness  of  the 
skin  itself  and  partly  to  the  waste  of  muscular  fibers  and  fat 
tissue.  The  hair  is  thin,  gray  or  white,  there  is  often  baldness, 
sometimes  there  is  an  excessive  growth  of  hair  in  unusual  places 
as  in  the  nose,  ears,  eyebrows,  and  on  the  upper  lip  of  women. 
The  nails  become  brittle  and  are  frequently  cracked,  they 
generally  show  neglect,  the  ends  being  broken  or  worn  off. 
Owing  to  the  impaired  circulation  and  defective  oxygenation  of 
the  blood  there  are  usually  cyanosed  lips,  pale  ears  and  areas  of 
passive  hyperemia  over  the  malars  and  at  the  tip  of  the  nose. 
The  waste  of  the  muscles  is  determined  by  their  activity.  In 
actors  and  public  speakers  who  make  frequent  use  of  the  facial 
muscles  in  giving  expression,  these  muscles  waste  in  bulk,  they 
present  tense  borders  leaving  the  muscles  in  sharp  outline.  In 
these  cases  the  muscle  texture  remains  unchanged.  Where  the 
facial  muscles  have  not  been  much  employed  they  become 
subjected  to  fatty  infiltration,  the  muscles  waste  late,  they  leave 
no  sharp  borders  and  they  are  soft  and  flabby.  This  condition 
is  well  seen  in  the  dull  ignorant  peasant  in  whom  the  masseters 
show  the  waste  due  to  activity  while  other  facial  muscles 
present  the  changes  referred  to.  In  this  class  too  do  we  find  the 
skin  much  darker  owing  to  exposure  and  rough  treatment. 

A  marked  senile  characteristic  which  itself  gives  the  im- 
pression of  lack  of  energy  is  the  atrophy  of  the  lower  maxilla, 
producing  the  so-called  weak  chin  of  the  physiognomists.     This 


14  PHYSIOLOGICAL   OLD   AGE 

atrophy  includes  loss  of  the  teeth  and  waste  of  the  alveolar 
process,  a  more  obtuse  angle  of  the  jaw  and  changes  in  the 
articular  surfaces,  causing  changes  in  the  anatomical  relations  of 
the  bones  of  the  face.  The  eyes  are  generally  lusterless  and  pre- 
sent a  gray  ring  around  the  cornea,  the  arcus  senilis.  There  is 
frequently  a  ptosis  of  the  upper  lids  and  occasionally  a  mild 
ectropion.  The  attitude  of  age  is  well  described  as  a  slouch. 
The  stature  is  diminished  through  compression  of  the  interver- 
tebral discs,  exaggeration  of  the  spinal  curvatures,  flattening  of 
the  pelvis,  depression  of  the  neck  of  the  femur  and  generally 
broken-down  arches.  There  is  also  an  apparent  decrease  in 
stature  owing  to  the  droop  of  the  head  and  the  bent  knees,  the 
former  being  due  to  weakness  and  waste  of  muscle,  the  latter 
being  caused  by  the  effort  of  the  individual  to  maintain  equilib- 
rium. A  psychic  cause  for  this  senile  slouch  will  be  described 
under  senile  debility.  The  senile  gait,  the  "abasia  senescent- 
ium"  of  Petrens,  is  a  halting  walk  with  slow,  short,  uncertain 
steps.  Naunyn  calls  it  a  neurosis  due  to  impaired  coordination. 
I  am  inclined  to  ascribe  this  gait  to  a  weakening  of  the  subcon- 
scious control  by  which  we  regulate  our  walk,  the  weakness  of 
the  muscles,  slowed  motor  impulses  and  the  stiffening  of  the 
joints  in  senility.  In  addition  there  is  usually  some  pedal  defect 
such  as  broken-down  arches,  hammer  toes,  bunions,  etc. 

The  most  profound  changes  occur  in  the  functions  of  the 
brain.  The  many  complex  factors  embraced  in  the  term 
mentality,  the  uncertainty  of  their  interrelations  and  our  ignor- 
ance of  the  mode  of  action  of  the  brain  preclude  any  lengthy 
discussion  of  this  subject.  The  senile  changes  in  mentality  are 
found  in  temperament,  emotions,  will,  sensations  and  intellect. 
The  most  prominent  mental  characteristic  in  old  age  is  an  over- 
whelming interest  in  self,  a  selfishness  which  gradually  subor- 
dinates every  other  interest  in  life  to  the  welfare  of  the  individual. 
Notwithstanding  all  the  optimistic  platitudes  of  philosophers 
from  the  days  of  Cicero  to  Metchnikoff,  notwithstanding  the 
inbred  resignation  of  the  fatalists,  the  ready  submission  to  the 
inevitable  of  the  materialists,  notwithstanding  the  promise  of 
heaven,  bliss  and  light  and  life  everlasting,  made  by  theologians 
of  all  ages,  man  looks  forward  to  death  with  dread  and  indigna- 
tion. And  the  nearer  he  approaches  the  abyss  beyond  which, 
he  is  told,  lies  eternal  life,  the  greater  his  dread,  the  more  pro- 


THE   SENILE   STATE 


IS 


found  is  his  sense  of  impotence,  the  more  depressing  is  his 
resignation.  In  the  healthy  mind  of  maturity  thoughts  of  death, 
when  they  arise,  are  set  aside,  for  future  reference  as  it  were, 
unless  some  circumstance  momentarily  forces  attention  to 
death.  When,  however,  the  infirmities  of  age  bring  such 
thoughts  persistently  and  with  ever-increasing  intensity  to  the 
individual,  life  assumes  a  value  incomprehensible  to  the  younger 
mind.  With  increasing  infirmities  and  the  realization  that  the 
span  of  life  is  rapidly  nearing  its  end,  the  desire  to  live  becomes 
the  all-absorbing  thought.  In  this  intense  desire  to  live  we  find 
the  basis  of  the  selfishness  of  the  aged.  It  is  also  the  cause  of 
his  suspiciousness,  his  egoism  and  temperamental  changes. 
There  are  contributing  causes  which  may  in  some  instances  be 
more  potent  than  the  causes  just  stated.  The  fear  of  leaving  a 
family  unprovided  for,  the  fear  of  becoming  a  burden  to  the 
family,  or  friends,  or  the  State,  may  produce  a  moroseness 
and  depression  which  would  change  the  temperament  of  the 
individual.  Likewise  would  the  irritability  caused  by  discom- 
forts produce  the  same  effect.  These  changes  affect  the  emotions 
and,  as  the  reasoning  power  diminishes,  its  ability  to  control 
the  emotions  wanes. 

In  old  age  a  stubborn  unreasoning  perverseness  often  takes 
the  place  of  a  reasonable  strong  will.  Of  the  intellectual 
faculties  memory  is  usually  the  first  to  show  impairment,  names 
and  numbers  being  quickly  forgotten.  Recent  events  unless 
directly  affecting  the  individual  are  not  firmly  impressed  upon 
the  mind  and  are  soon  forgotten,  while  early  events  are  readily 
recalled.  In  those  accustomed  to  employ  the  reasoning  faculty, 
this  faculty  generally  remains  unimpaired  so  far  as  the  quality 
of  the  work  is  concerned,  but  greater  mental  effort  is  required 
and  brain  fatigue  sets  in  more  rapidly.  In  some  individuals 
all  of  the  intellectual  faculties  become  uniformly  weakened, 
producing  a  progressive  senile  dementia.  There  is  a  marked 
change  in  mentality  during  the  senile  climacteric  which  will  be 
described  further  on. 

In  this  brief  review  of  the  obvious  changes  that  occur  as  a 
result  of  ageing,  special  stress  has  been  laid  upon  the  mental 
changes,  as  they  are  often  the  first  indications  that  the  period 
of  decline  has  begun.  Lessened  interest  in  the  events  of  the 
day,    a  v  tendency,;  to   sleep   after   some   mental   work,    greater 


1 6  PHYSIOLOGICAL   OLD   AGE 

difficulty  in  getting  ideas  or  some  particular  word  to  express 
ideas,  forgetfulness,  all  point  to  senile  changes  in  the  brain. 

The  subjective  indications  of  advancing  age  do  not  corre- 
spond with  the  objective  manifestations.  In  many  cases  of  men 
the  first  change  which  attracts  the  attention  of  the  individual  is 
lessened  sexual  power  without  diminished  desire.  Occasionally 
the  desire  first  wanes  and  in  such  cases  there  arises  often  sexual 
perversion.  In  many  cases  the  individual  complains  of  pains 
and  aches  in  the  muscles  and  joints  which  he  ascribes  to  rheuma- 
tism, or  of  shortness  of  breath  which  he  says  is  asthma,  or  of  a 
desire  to  sleep  after  ordinary  mental  or  physical  work  and  this 
he  calls  malaria.  Some  men  will  take  the  first  gray  hair  as  an 
indication  of  ageing  and  this  is  the  only  obvious  manifestation 
which  the  individual  will  notice  before  others.  Many  persons 
will  deny  any  feeling  of  age,  even  when  such  pronounced 
symptoms  as  dyspnea,  palpitation  of  the  heart,  pains  and  aches 
in  muscles  and  joints,  and  diminished  capacity  for  all  kinds  of 
work  are  present. 

While  nearly  all  that  has  been  said  applies  to  women  as  well 
as  to  men,  there  are  some  differences  in  both  the  objective  and 
subjective  manifestations  between  the  sexes.  Many  women 
begin  to  lose  energy  and  power  immediately  after  the  meno- 
pause, and  this  may  be  looked  upon  as  the  earliest  of  the  sub- 
jective manifestations  of  ageing.  Objectively  we  find  a  growth 
of  hair  upon  the  upper  lip,  a  waste  of  the  muscles  of  the  neck, 
deposit  of  adipose  tissue  upon  the  abdomen.  The  senile  kypho- 
sis is  not  as  marked  in  women  as  in  men.  This  is  due  partly  to 
the  effort  to  maintain  an  erect  bearing  and  to  present  a  pleasing 
appearance,  partly  to  the  support  given  to  the  back  by  corsets 
and  stays,  and  partly  to  the  slighter  downward  pressure  exerted 
upon  the  spinal  column  by  wearing  the  dresses  suspended  from 
the  hips  instead  of  from  the  shoulders.  The  mental  changes  in 
the  female  generally  include  all  the  intellectual  faculties  and 
proceed  to  the  extent  of  complete  dementia  far  more  often  than 
in  the  male. 

The  obvious  manifestations  of  senility  appear  later  in  the 
female,  for  the  reason  that  she  makes  an  effort  to  remain  at- 
tractive, the  psychic  factor  involved  in  the  production  of  the 
senile  slouch  in  the  male  being  overcome  by  her  vanity,  there 
is  absent  the  senile  kyphosis,  the  marked  waste  of  the  facial 


THE    SENILE    STATE 


17 


muscles,  and  often  the  wrinkles  generally  seen  in  the  male. 
Women  being  more  impressionable  than  men,  they  are  more 
amenable  to  religious  teachings,  they  become  more  readily  re- 
signed to  the  inevitable  through  their  faith  and  hope  of  eternal 
life  hereafter,  and  being  more  cheerful  they  do  not  present  the 
disagreeable,  gloomy  appearance  of  aged  men.  This  as  well  as 
their  sex  brings  to  them  the  sympathy  denied  to  men. 

Our  conception  of  old  age  must  be  based  upon  the  harmoniza- 
tion of  the  objective  manifestations,  of  the  subjective  mani- 
festations and  the  organic  (physical  and  mental)  changes  so 
far  as  we  can  determine  them.  In  considering  the  objective 
symptoms  we  must  exclude  the  slouch  due  to  laziness,  the  care- 
worn expression  due  to  worry,  the  waste  of  muscle  from  disease 
and  insufficient  food,  the  roughened  skin  due  to  exposure  or 
improper  treatment,  the  kyphosis  due  to  certain  vocations  as  well 
as  to  disease,  the  peculiar  gait  of  various  nervous  disorders  and 
the  mental  weakness  of  cerebral  disease.  The  subjective  symp- 
toms may  be  due  to  various  diseases.  Of  the  organic  changes 
only  one  has  been  found  to  be  invariably  due  to  ageing.  This  is 
the  progressive  increase  of  interstitial  fibers  between  the  pyramids 
of  the  kidneys,  first  described  by  Doctor  Jos.  Walsh  of  Phila- 
delphia. Every  other  senile  change  in  the  organism  may  also 
be  found  as  a  pathological  process  in  maturity,  and  it  is  often 
difficult  to  determine  whether  the  change  is  due  to  ageing  or  to 
disease.  The  difficulty  is  increased  by  the  fact  that  changes 
due  to  ageing  have  been  demonstrated  in  early  maturity  yet  give 
no  manifestations,  objective  or  subjective,  until  two  or  three 
decades  later.  Diminution  in  respiratory  capacity  begins 
about  the  end  of  the  fourth  decade  yet  difficult  respiration  due 
to  the  atrophy  of  the  lungs  may  not  manifest  itself  until  the 
sixth  decade  or  later.  The  brain  begins  to  lose  in  weight  during 
the  fourth  decade,  sclerotic  and  atheromatous  changes  in  the 
blood-vessels  without  apparent  cause  or  complicating  disease 
have  been  observed  in  the  third  decade,  while  cardiac  hyper- 
trophy has  been  found  in  athletes  before  the  third  decade.  The 
popular  conception  of  old  age  is  based  upon  the  appearance  of 
the  individual.  It  is  not  unusual,  however,  to  find  apparently 
decrepit  individuals  regain  strength,  mental  activity,  cheerful- 
ness and  a  more  buoyant  spirit  as  well  as  a  more  youthful 
appearance  when  freed  from  care  and  the  necessity  to  work. 


1 8  PHYSIOLOGICAL   OLD   AGE 

This  is  a  common  observation  in  inmates  of  homes  for  the  aged, 
shortly  after  their  admission.  A  conception  of  old  age  based 
upon  the  subjective  manifestations  may  be  equally  fallacious, 
as  these  may  be  symptoms  of  true  pathological  processes,  or 
due  to  temporary  psychic  influences.  Neither  can  we  base 
our  conception  of  old  age  upon  the  organic  changes  due  to  ageing, 
as  these  may  appear  in  early  maturity.  The  term  old  age 
should  be  applied  only  to  such  cases  as  present  obvious  mani- 
festations or  marked  subjective  symptoms  with  the  progressive 
organic  changes  which  are  due  to  ageing.  The  term  senility  is 
usually  applied  to  a  more  advanced  old  age.  It  implies  pro- 
nounced senile  changes  with  the  accompanying  objective  and 
subjective  manifestations,  and  covers  the  period  from  the  time 
when  the  mental  and  physical  impairment  begins  to  incapaci- 
tate the  individual,  to  the  complete  decrepitude  that  ends  in 
physiological  death.  It  corresponds  to  the  postclimacteric 
stage  of  the  period  of  decline. 

During  this  climacteric  there  is  a  readjustment  in  the 
relations  between  the  functions,  and  changes  in  the  organs 
necessary  to  carry  out  the  new  functional  relations.  There  is 
no  regularity  in  the  order  or  rapidity  with  which  organs  and 
tissues  undergo  senile  involution,  and  consequently  we  find 
vast  differences  in  the  mental  and  physical  condition  of  indi- 
viduals of  the  same  age.  There  is  a  time,  generally  about  the 
latter  part  of  the  seventh  or  eighth  decade,  when  profound 
changes  occur  both  mentally  and  physically.  This  is  the 
transitional  period  between  old  age  and  senility  and  corresponds 
to  the  critical  period  that  occurs  during  the  period  of  develop- 
ment called  puberty  and  the  critical  period  during  the  period  of 
maturity  called  the  menopause  in  the  female.  I  have  called 
this  critical  period  in  the  period  of  decline,  the  senile  climacteric. 
-/Some  at  that  age  show  little  physical  impairment,  while  others 
are  decrepit.  Usually  there  is  mental  depression  with  some 
impairment  of  the  faculties,  lessened  activity,  and  degeneration 
of  some  organs  and  tissues,  due  to  arteriosclerosis  or  primary 
degeneration,  while  other  organs  and  tissues  show  little  change. 
In  those  who  have  lived  slow,  rational  lives,  the  senile  changes 
proceed  slowly,  gradually,  and  harmoniously.  Most  individuals 
are  so  situated  or  so  constituted  that  greater  stress  is  put  upon 
some  organs  and  tissues  than  upon  others,  and  these  degenerate 


Left    femur   of    a   colored  man.     Large  black 
spaces  represent  senile  absorption  of  bone. 


A  single  Haversian  system, 
much  enlarged,  without  defi- 
nite signs  of  sensility. 


A  single  Haversian  system, 
much  enlarged,  showing  early 
signs  of  senility. 


A  single  Haversian  system,  A  single  Haversian  system, 

much  enlarged,  showing  a  later  much    enlarged,    showing    the 

stage  of  senility.  latest  stage  of  senility. 

Senile  changes  in  the  human  femur.     (J.  S.  Foote,  Smithsonian  Miscellaneous  Collec- 
tions, Vol.  61,  No.  8.) 


THE    SENILE    STATE 


19 


faster  than  the  others.  As  a  result  of  the  unequal  rate  of  degen- 
eration in  the  organs,  the  harmonious  interaction  of  functions 
is  disturbed,  and  we  have  pathological  conditions,  giving  ob- 
jective and  subjective  manifestations  of  disease.  In  nature's 
effort  to  effect  a  readjustment  of  the  functions  during  the  senile 
climacteric  those  organs  which  have  degenerated  slowly  now 
degenerate  rapidly,  while  the  degenerative  changes  in  those 
organs  which  have  been  most  involved  are  retarded. 

Among  the  earliest  of  the  obvious  changes  that  occur  in  the 
senile  climacteric  is  a  change  in  the  mentality  of  the  individual. 
There  is  a  change  in  mentality  at  the  beginning  of  the  period  of 
decline,  due  partly  to  the  recognition  by  the  individual  that 
he  is  entering  upon  the  closing  period  of  life,  and  partly  to  weak- 
ening of  the  intellectual  faculties.  A  more  profound  change 
occurs  during  the  senile  climacteric.  There  are  now  periods  of 
emotional  exaltation  followed  by  depression.  At  times  there  is 
mental  confusion  with  delusions  which  are  soon  forgotten, 
flashes  of  former  mental  vigor  during  which  brilliant  work  may 
be  done  but  if  such  work  is  prolonged  beyond  a  few  minutes  or 
hours  the  character  of  the  work  deteriorates  and  it  becomes 
confused  and  finally  it  becomes  unintelligible,  memory  is  dulled 
and  cannot  be  stimulated  by  any  process  of  mnemonics.  There 
are  lucid  intervals  during  which  there  is  no  evidence  of  mental 
deterioration  except  perhaps  weakened  memory.  Gradually, 
however,  this  period  merges  into  the  postclimacteric  period,  the 
periods  of  exaltation  become  less  pronounced  and  less  frequent, 
and  the  depression  gives  way  to  apathy,  the  reasoning  power 
wanes  rapidly,  the  intense  biophilism,  or  love  of  life,  that  marks 
the  early  stage  of  senility,  passes  away.  Interest  in  all  direc- 
tions is  diminished,  the  individual  becomes  garrulous,  seeks  the 
association  of  children  in  preference  to  adults,  and  falls  into 
childish  ways.  Occasionally  there  is  a  recrudescence  of  sexual 
desire,  to  gratify  which  he  may  attempt  rape  upon  little  girls. 
Such  crimes  do  not  arise  from  depravity,  but  through  weakened 
mentality  involving  a  weakened  moral  sense,  inability  to 
realize  the  nature  of  the  act  or  its  consequences,  a  loss  of  control 
over  conduct,  and  an  irrepressible  sexual  fury.  Such  acts 
occur  almost  invariably  during  the  senile  climacteric. 

Especially  noticeable  during  this  period  is  a  change  in  facial 
expression,  corresponding  with  the  mental  change.     At  the  same 


20  PHYSIOLOGICAL   OLD   AGE 

time  the  strength  diminishes,  and  the  individual  is  forced  to 
use  a  cane;  in  some  cases  this  is  accompanied  by  senile  tremor, 
rarely  by  a  pseudoosteitis  deformans.  Owing  to  the  rapid 
degeneration  of  those  organs  which  had  shown  but  little  senile 
change  before,  these  organs  are  peculiarly  liable  to  disease,  hence 
we  find  most  deaths  in  the  early  part  and  middle  of  the  eighth 
decade  resulting  from  diseases  in  organs  that  were  apparently 
healthy  before  the  final  illness.  While  these  organs  may  have 
degenerated  before  the  climacteric,  the  process  had  proceeded  so 
slowly  and  gradually  as  to  give  no  subjective  or  objective 
symptoms.  This  is  especially  noticeable  in  the  heart.  If  the 
heart  has  not  been  subjected  to  excessive  strain  before  this  time, 
the  cardiac  hypertrophy  kept  pace  with  the  demands  made 
upon  the  organ.  Now,  however,  it  has  reached  the  limit  of 
its  ability  to  compensate  for  the  impaired  circulation  due  to 
arteriosclerosis  and  valve  defects,  and  it  begins  to  dilate.  In  a 
series  of  forty-five  deaths  between  the  ages  of  seventy  and  eighty 
years,  occurring  in  a  fraternal  order,  there  were  ten  deaths  from 
various  forms  of  heart  disease  and  five  from  arteriosclerosis. 

Other  changes  that  may  be  noted  at  this  time  are  the  rapid 
whitening  of  the  hair,  where  it  had  thus  far  retained  its  color, 
while  the  falling  out  of  hair  ceases.  The  skin  becomes  thin, 
loose,  and  transparent;  in  some  cases  there  is  a  growth  of  warts 
or  other  excrescences.  The  dyspnea  of  senile  emphysema  fre- 
quently disappears  as  the  impaired  heart  sends  less  blood  to  the 
lungs,  thus  reestablishing  harmonious  relations  between  the 
two  organs.  A  similar  readjustment  in  the  functional  relations 
of  allied  organs  is  often  found  in  the  activities  of  the  stomach 
and  intestines.  The  loss  of  teeth  necessitating  a  change  in 
diet,  and  change  in  the  functional  activity  of  the  digestive  organs, 
possibly,  too,  a  change  in  the  taste  for  certain  kinds  of  food, 
cause  a  change  in  the  nutrition  of  the  aged  individual.  Insipid 
articles  of  food  become  distasteful.  Such  substances  are  usually 
alkaline  in  reaction  and  are  indigestible  in  the  stomach  owing 
to  the  subacidity  of  the  gastric  juice.  There  is  generally  a  dis- 
like for  fat  and  at  the  same  time  the  secretion  of  bile  is 
diminished.  Underdone  meat,  a  frequent  source  of  constipa- 
tion, is  rejected  partly  on  account  of  the  inability  to  chew 
it  and  partly  on  account  of  distaste.  Acids  and  sharp,  spiced 
condiments  are  relished,  and  these  aid  digestion   and  are   of 


-JV 


M 


M& 


■4^ 
f. 


The  skull  of  a  woman  eighty-three  years  old,  to  show  the  changes  in  the  mandible 
and  maxilla.     (From  Moriis'  "Human  Anatomy.") 


ANATOMICAL   CHANGES   IN   OLD   AGE  21 

service  in  the  senile  constipation.  On  account  of  diminished 
appetite  there  are  longer  intervals  between  meals,  and  this  pre- 
vents overloading  the  stomach  and  the  addition  of  food  to 
undigested  food  already  in  the  stomach.  At  this  time  the  aged 
individual  demands  food  in  the  form  of  mush  or  liquid,  and 
softer  stools  are  produced,  lessening  the  danger  of  fecal  im- 
paction and  favoring  more  rapid  elimination. 

I  should  ascribe  the  relief  frequently  obtained  in  the  post- 
climacteric period  from  the  trouble  of  senile  constipation  of  the 
earlier  period  to  this  change  in  diet  and  digestion  and  not  to  the 
cathartics  that  may  have  been  given  for  years  before.  The 
senile  climacteric  may  last  a  few  months  or  even  a  year  or  more. 
Its  inception  and  completion  are  gradual,  it  presents  no  specific 
manifestation  as  occurs  in  the  female  in  puberty  and  the 
menopause,  nor  are  the  differences  in  the  organism  between  the 
preclimacteric  and  the  postclimacteric  periods  as  marked  as 
between  the  prenubile  and  postnubile  stages  of  the  period  of 
development  or  the  preclimacteric  and  postclimacteric  stages  of 
maturity.  After  the  senile  climacteric  has  passed,  there  is  a 
uniform  decadence  of  mind  and  body.  The  intellectual  faculties 
become  gradually  weaker,  but  rarely  reach  the  stage  of  complete 
dementia.  Muscle  tonicity  and  nervous  activity  gradually 
lessen,  breathing  becomes  slower  and  more  shallow,  heart  action 
becomes  weak,  assimilation  becomes  more  difficult,  and  elimina- 
tion is  diminished.  If  no  one  organ  is  excessively  strained  or 
irritated,  the  functions  maintain  their  harmonious  relations  to 
each  other,  gradually  weakening,  until  complete  cessation  in 
physiological  death. 

ANATOMICAL  CHANGES  IN  OLD  AGE 

The  anatomical  changes  due  to  old  age  are  of  the  most 
diverse  character,  they  are  neither  uniform  nor  regular  nor  do 
we  always  find  like  changes  in  similar  tissues  in  different  indi- 
viduals, until  late  in  life,  when  changes  become  uniform  and  we 
find  like  organs  subjected  to  like  changes. 

The  changes  in  bone  include  waste  of  organic  matter  with 
consequent  proportionate  increase  in  inorganic  matter  whereby 
bones  become  more  brittle,  they  fracture  more  readily  and 
repair  is  more  difficult ;  there  is  osteoporosis  of  the  short  bones, 
of  the  epiphyses  of  long  bones  and  of  the  diploe  of  flat  bones; 


22  PHYSIOLOGICAL   OLD    AGE 

late  in  life  there  is  a  waste  or  resorption  of  the  entire  bone  sub- 
stance. Irregular  waste  and  pressure  cause  changes  in  the  shape 
of  bones.  Marked  changes  are  found  in  the  skull,  spinal 
column,  thorax,  pelvis,  femurs  and  feet. 

Cranial  bones  become  thin,  local  waste  occasionally  proceed- 
ing to  the  extent  of  complete  perforation,  the  edges  of  the  opening 
being  raised  through  the  increased  osteoporosis  of  the  diploe  over 
the  wasted  area,  and  the  sutures  become  obliterated.  The  most 
pronounced  osseous  waste  is  found  in  the  lower  maxilla.  Owing 
to  the  loss  of  the  teeth  and  the  consequent  absorption  of  the 
alveolar  process,  the  chin  must  be  raised  higher  in  the  act  of 
closing  the  mouth,  the  condyles  are  consequently  brought 
further  down  and  back,  the  rami  become  oblique  and  the  angles 
of  the  jaw  become  obtuse.  There  is  at  the  same  time  a  general 
atrophy  of  the  bone,  the  chin  becomes  more  pointed,  the  mental 
foramen  is  smaller  and  on  account  of  the  waste  of  the  body  of 
the  bone  it  is  found  near  the  alveolar  border.  These  changes 
in  the  lower  maxilla  produce  the  weazened  face  of  old  age.  The 
changes  in  the  spinal  column  are  due  mainly  to  changes  in  the 
intervertebral  discs  and  will  be  described  under  cartilage  changes, 
and  under  the  same  heading  will  be  found  the  thoracic  changes, 
The  changes  in  the  pelvis  are  waste,  osteoporosis  and  change 
in  shape,  the  last  being  the  most  noticeable.  Owing  to  the 
constant  downward  pressure  upon  the  sacrum  this  bone  is  pushed 
back,  the  angle  of  the  sacro-lumbar  articulation  becomes  more 
acute,  there  is  anchylosis  of  the  sacrum  and  coccyx  and  the 
sacro-iliac  relations  become  altered,  the  ilia  being  forced  back- 
ward to  accommodate  themselves  to  the  changed  position  of  the 
sacrum.  Between  this  downward  and  backward  pressure  of  the 
sacrum  and  the  upward  pressure  exerted  by  the  femurs  the  whole 
pelvis  becomes  vertically  compressed  and  horizontally  expanded. 
The  width  of  the  pelvis  is  apparently  increased  still  more  through 
waste  of  the  glutei  muscles  and  through  changes  in  the  neck  of 
the  femur  which  bring  the  greater  trochanter  higher  and  further 
out.  The  ilia  become  thin,  the  pubes  undergoes  osteporosis  and 
late  in  life  wastes,  the  acetabuli  become  shallow  and  larger 
through  the  waste  of  the  surrounding  bone.  The  principal 
change  in  the  femur  is  found  in  the  relation  between  neck  and 
shaft.  In  maturity  they  form  an  angle  of  about  145  degrees, 
but  in  old  age  the  neck   becomes  depressed  until  the   angle 


I 
II 


\ 


Spinal  perpendicular  index.  Showing  relation  of  length  of  spinal  column  to 
perpendicular  line  from  atlas  to  tip  of  coccyx.  Infancy,  ioo  :  95-97.  Matu- 
rity, 100:  88-95.     Old  age,  100  :  So-90. 


ANATOMICAL   CHANGES   IN   OLD   AGE  23 

formed  approaches  a  right  angle.  Osteoporosis  destroys  the 
arrangement  of  the  cancellous  structure  of  the  neck,  the  bone 
being  thereby  weakened,  thus  accounting  for  the  frequency  of 
fracture  of  the  neck  of  the  femur  in  old  age.  Other  changes  in 
the  femur  are  such  as  occur  in  all  long  bones.  Broken-down 
arches  of  the  feet  are  found  generally  in  the  aged.  It  may  be 
questioned  whether  this  is  a  physiological  or  a  pathological 
condition  in  old  age.  It  is  due  to  the  downward  pressure  upon 
the  feet  and  weakness  of  the  tendons,  and  frequently  to  improper 
shoes. 

The  cartilage  changes  are  waste,  ossification,  calcification  and 
formation  of  fibrous  tissue.     The  articular  cartilages  become 
dry,  then  thin  and  through  attrition  they  become  fibrillated  and 
waste.     In  the  larynx  the  thyroid,  cricoid  and  arytenoid  carti- 
lages ossify  while  the  epiglottis  becomes  fibrous.     The  carti- 
laginous rings  of  the  trachea  sometimes  ossify  and  occasionally 
the  bronchial  cartilages  suffer  likewise.     In  the  sternum  com- 
plete bony  union  of  the  parts  of  the  gladiolus  takes  place  before 
the  thirty-fifth  year.     About  the  same  time  the  cartilage  be- 
tween the  manubrium  and  the  gladiolus  begins  to  calcify,  the 
ensif  orm  cartilage  ossifies  and  later  ossification  takes  place  in  the 
costal  cartilages.     In  old  age  all  these  tissues  become  anchylosed 
forming  with  the  ribs  and  spinal  column  a  rigid  thorax.     The  in- 
tervertebral discs  begin  to  calcify  about  the  fiftieth  year.    Owing 
to  the  constant  downward  pressure  upon  the  spinal  column 
when  the  body  is  erect  these  discs  become  compressed.     In 
maturity  the  discs  are  elastic  and  when  the  pressure  is  relieved 
(as  in  the  recumbent  position)  the  discs  resume  their  natural 
shape.     This  accounts  for  the  greater  stature  in  the  morning 
than  at  night.     This  expansibility  of  the  discs  is  lost  when  they 
calcify  and  the  diminished  stature  becomes  permanent.     The 
pressure  is  greatest  where  the  discs  are  thinnest,  anteriorly  m 
the  dorsal  region  and  posteriorly  in  the  cervical  and  lumbar 
regions.     The  compression  is  not  so  great  in  the  cervical  region 
and   the  lumbar   discs   are   thicker   and   more   uniform.     The 
greater  compression  of  the  anterior  portion  of  the  dorsal  discs 
spreads  the  posterior  borders  and  causes  the  increased  curva- 
ture of  the  spine  in  that  region  in  old  age.     It  also  produces  an 
approximation  of  the  facets  whereby  a  more  acute  articular 
angle  with  the  ribs  is  produced.  The  ribs  in  order  to  accommo- 


24  PHYSIOLOGICAL   OLD    AGE 

date  themselves  to  the  changed  articular  relations  in  the  back 
and  the  ossified  costal  cartilages  in  front  become  flattened  at 
the  sides.  These  changes,  together  with  the  lessened  resilience 
of  the  ribs  owing  to  the  waste  of  organic  matter,  occasion  the 
senile  chest  which  resembles  the  rachitic  chest,  being  longer  in 
front,  shorter  in  the  back  and  flattened  at  the  sides. 

The  changes  in  the  ligaments  are  hardening  and  contraction. 
The  ligamentum  nuchse  is  sometimes  lengthened  but  never 
flaccid.  The  most  marked  changes  are  found  in  the  capsular 
ligaments  in  which  the  hardening  and  contraction  may  proceed 
to  the  extent  of  complete  immobilization  of  a  joint.  Stiff  joints 
from  this  cause  are  quite  frequent  but  are  often  diagnosed  as 
rheumatic  arthritis.  The  changes  in  muscle  are  atrophy,  fatty 
infiltration,  fatty  degeneration,  stretching  and  in  the  case  of  the 
heart,  hypertrophy. 

In  active  muscles  there  is  primary  atrophy  through  the  waste 
occasioned  by  muscular  action,  the  waste  not  being  fully  repaired. 
In  inactive  muscles  there  is  a  secondary  atrophy  following  fatty 
infiltration,  the  fat  cells  displacing  muscle  fiber  and  appropri- 
ating nutrition  of  the  muscles.  The  difference  between  the  atro- 
phic and  the  fatty  changes  is  seen  in  comparing  the  two  biceps 
of  the  aged  artisan,  the  right  being  smaller  but  maintaining 
its  muscle  consistency  and  strength  in  proportion  to  its  mass, 
while  the  left  is  flabby,  there  is  but  little  waste  and  the  loss  of 
strength  is  greater  than  in  the  right.  The  differences  in  the 
changes  in  the  facial  muscles  between  the  actor  and  the  dull 
peasant  have  been  referred  to.  The  greatest  waste  occurs  in 
the  intercostals,  these  being,  after  the  heart,  the  most  actively 
employed  muscles  of  the  body.  The  heart  muscle  hypertrophies, 
rarely  atrophies.  Fatty  infiltration  and  fatty  degeneration  of 
the  heart  which  are  sometimes  found  in  the  heart  of  the  aged 
are  pathological  and  due  to  impaired  nutrition.  We  sometimes 
find  a  pseudohypertrophy  of  the  muscles  due  to  the  prolifera- 
tion of  connective-tissue  fibers  through  the  muscle  fibers.  This 
occurs  in  the  walls  of  the  bladder  whereby  bands  are  formed  with 
pouches  and  pockets  between  them. 

The  changes  in  the  skin  are  of  the  most  varied  character 
including  atrophy,  localized  and  more  extensive  areas  of  hyper- 
trophy, anemia,  congestion,  pigmentation  and  changes  in  the 
character  of  the  cells  of  the  various  tissues  forming  the  skin. 


Section  of   the   Head  of   the 
(From  Minot's  "Problems  of  A< 
New  York  and  London.) 


Thigh    Bone  of  a   Man  of  Thirty-seven  Years. 
;e,   Growth  and  Death."     G.  P.  Putnam's  Sons, 


Section  of  the  Head  of  the  Thigh  Bone  of  a  Woman  of  Eighty-two  Years. 
Shows  also  depression  of  head  of  femur.  (From  Minot's  "Problems  of  Age, 
Growth  and  Death."     G.  P.  Putnam's  Sons,  New  York  and  London  ) 


ANATOMICAL  CHANGES  IN  OLD  AGE  2  "C 

There  is  generally  waste  of  the  subcutaneous  fat,  atrophy  of 
the  derma,  the  areolar  tissue  becomes  fibrillated,  the  connective 
tissue  becomes  loose  and  separates,  the  glands  waste  and  there 
is  waste  of  the  elastic  fibers.  As  a  result  of  these  changes  the 
skin  becomes  dry,  lusterless,  loose  and  flabby.  In  some  locali- 
ties the  sweat  glands  exhibit  greater  activity  and  the  character 
of  the  secretion  is  changed.  Pigment  is  deposited  in  the  rete 
Malpighii,  sometimes  localized  as  ecchymotic  spots  on  the  hands, 
neck  and  other  exposed  portions  of  the  body,  sometimes  covering 
more  extensive  areas.  In  some  localities  there  may  be  extensive 
brown  patches  due  to  passive  congestion.  Folds  and  wrinkles 
are  caused  by  waste  of  fat  and  elastic  fibers.  The  hypertrophies 
take  the  form  either  of  thickened  epidermis  on  the  hands  or 
feet  or  there  may  be  hard  or  soft  warts.  There  is  loss  of  pig- 
ment in  the  hair,  the  hair  bulbs  generally  atrophy  causing  falling 
out  of  the  hair  although  there  is  often  an  abnormal  growth  in 
unusual  places  as  in  the  nostrils,  ears,  etc.  The  nails  become 
dry  and  brittle.  The  skin  is  generally  cold  and  where  not  pig- 
mented it  is  pale,  on  account  of  the  deficient  circulation,  or  it 
presents  areas  of  local  passive  hyperemia.  There  is  generally 
degeneration  of  the  nerve  terminals  producing  various  sensory 
disturbances. 

The  most  important  senile  changes  occur  in  the  circulatory 
system.  The  hypertrophy  of  the  heart  is  usually  the  earliest 
of  these  changes  but  the  changes  in  the  blood-vessels  produce  the 
most  profound  disturbances  in  the  organism.  The  earliest  change 
in  the  arteries  is  a  hyperplasia  of  the  connective  tissue  of  the 
intima  with  consequent  stiffening  of  the  vessel,  thickening  of 
the  inner  coat  and  diminution  of  the  caliber.  This  is  accom- 
panied or  followed  by  a  waste  of  the  elastic  fibers  whereby  the 
elasticity  of  the  artery  is  diminished.  These  changes  in  the 
vaso  vasorum  cause  diminished  circulation  through  them,  in- 
terfering with  the  nutrition  of  the  larger  vessels  and  conse- 
quently these  vessels  degenerate.  The  inner  coat  becomes  soft, 
fat  deposits  and  we  find  atheromatous  foci  or  plaques  on  the 
surface  of  the  inner  coat.  Later  results  of  defective  nutrition 
are :  waste  of  muscle  fibers,  hardening  of  the  outer  coat,  calcareous 
deposits  in  the  inner  and  middle  coats,  and  finally  calcification 
of  the  entire  vessel.  Before  calcification  the  vessel  is  harder 
than  normal  and  tortuous.     After  partial  calcification  the  vessel 


26  PHYSIOLOGICAL   OLD   AGE 

feels  beady  but  the  pulse  can  be  felt.  In  diffuse  calcification 
the  vessel  is  rigid  and  in  extreme  cases  the  pulse  is  absent,  the 
vessel  feeling  like  a  hardened  tendon.  Such  extreme  cases  are, 
however,  rare.  Advanced  arteriosclerosis  is  most  frequently- 
found  in  the  aorta,  the  cerebral  vessels,  thecoronaries,  the  radials, 
vertebrals,  carotids,  splenic,  brachial,  iliac  and  femoral  arteries. 
The  aorta  is  almost  invariably  affected,  being  dilated  and  show- 
ing extensive  fatty  and  calcareous  plates  in  the  ascending  and 
often  in  the  transverse  portions.  The  diminution  of  caliber 
in  the  smaller  vessels  may  extend  to  complete  obliteration  of 
the  lumen,  thereby  depriving  the  parts  beyond  of  nutrition. 
This  causes  gangrene  or  other  destruction  of  tissue.  The  earliest 
change  in  the  heart  is  hypertrophy  and  this  may  begin  during 
the  period  of  development.  Cardiac  hypertrophy  which  is  the 
normal  condition  of  the  heart  of  the  aged  cannot  be  called  a 
senile  degeneration,  as  the  same  causes  that  prevail  in  old  age 
prevail  in  the  earlier  periods  of  life.  Whatever  tends  to  make 
the  heart  act  faster  or  more  powerfully  tends  to  cause  it  to  hyper- 
trophy. Excessive  activity,  elevation  of  temperature,  nervous 
influences,  will  cause  hypertrophy,  as  well  as  the  greater  force 
required  to  send  the  blood  through  the  contracted,  inexpansible 
blood-vessels.  The  heart  in  the  aged  is  heavier  and  larger  than 
in  maturity,  the  average  weight  in  the  male  being  n  ounces  and 
in  the  female  91/2  ounces  (Loomis).  The  cavities  are  increased, 
the  proportionate  capacity  remaining  unchanged.  The  left 
ventricular  wall  is  much  thicker  than  the  walls  of  the  other 
cavities,  being  thickest  just  below  the  level  of  the  mitral  valve 
and  diminishing  rapidly  toward  the  apex.  The  valves  are  thick- 
ened and  the  valvular  orifices  are  enlarged.  The  aortic  opening  is 
larger  than  the  others  and  aortic  insufficiency  is  the  rule  in  old 
age.  The  endocardium  undergoes  the  same  changes  that  are 
found  in  the  inner  coat  of  the  arteries  including  fatty  plaques  and 
calcareous  deposits.  The  more  pronounced  changes  resembling 
chronic  endocarditis  will  be  described  under  senile  endocarditis. 
Myocarditis,  the  fatty  degenerations,  and  atrophy  of  the  heart 
will  be  treated  as  diseases.  The  changes  in  the  veins  are  similar 
to  the  early  changes  in  the  arteries.  The  inner  coat  becomes 
soft  and  there  is  loss  of  the  elastic  and  muscle  fibers  of  the  other 
coats.  The  veins  rarely  become  hard,  but  the  waste  of  the 
elastic  fibers  allows  a  dilatation  of  the  vessels.     They  are  often 


ANATOMICAL  CHANGES  IN  OLD  AGE  2  7 

tortuous  and  occasionally  we  can  feel  a  venous  pulsation,  espe- 
cially in  the  neck.  The  veins  are  usually  filled  to  ex  with 
a  slow-flowing  current  of  blood,  this  condition  being  known  as 
venosity.  The  principal  pulmonary  change  is  atrophy  of  the 
lung.  There  is  diminution  in  size  and  weight,  the  lung  is  com- 
pressed through  the  changes  in  the  thorax,  its  expansibility  is 
diminished,  the  bronchioles  show  extensive  dust  deposits  parti  ally 
occluding  their  lumen,  producing  pneumokoniosis,  the  septa  be- 
tween the  alveolae  waste  and  the  air  vesicles  consequently  coalesce, 
producing  senile  emphysema.  The  senile  lung  is  grayish  with 
black  spots  and  lines  over  its  surface  and  throughout  its  mass, 
and  dilated  or  ruptured  air  vesicles  are  clearly  seen  on  section 
as  minute  cavities.  The  lung  has  a  more  elastic  feel  than  in 
maturity  but  with  diminished  crepitation.  In  advanced  senility 
when  the  atrophy  is  very  marked  they  lie  close  to  the  vertebral 
column,  their  surface  is  uneven,  the  upper  lobe  of  the  left  lung 
sinks  and  falls  forward  of  the  lower  lobe,  so  that  the  upper  lobe 
is  in  front  and  the  lower  one  is  behind  it,  while  in  the  right  lung 
the  middle  lobe  sinks  and  falls  in  front  of  the  lower  one.  We 
sometimes  find  the  lower  lobe  of  the  right  lung  overlapping  the 
upper  one  posteriorly.  The  respiratory  capacity  diminishes. 
The  decrease  has  been  demonstrated  in  the  early  part  of  the  fourth 
decade,  but  not  until  it  is  far  advanced  are  marked  objective  or 
subjective  manifestations  produced.  The  loss,  which  is  about 
1/2  per  cent,  of  the  total  capacity  per  annum  at  thirty-five, 
rises  to  i  per  cent,  or  more  about  sixty.  The  trachea  and  the 
upper  part  of  the  bronchi  become  rigid  and  frequently  contain 
calcareous  incrustations,  the  bronchioles  have  their  calibers 
diminished  and  occasionally  the  lumen  is  entirely  closed.  The 
pleura  becomes  thin,  dry,  lusterless,  opaque,  the  layers  are 
generally  adherent  to  each  other  and  the  outer  layer  is  adherent 
to  the  chest  wall.  The  changes  in  the  digestive  tract  are  found 
throughout  its  entire  length.  The  teeth  fall  out,  the  alveolar 
process  of  the  lower  maxilla  wastes,  the  salivary  glands  atrophy 
and  their  secretions  are  diminished  but  not  altered  in  composi- 
tion. The  stomach  becomes  dilated  through  atony  and  waste 
of  the  muscular  fibers,  there  is  an  atrophy  of  the  glands,  the 
mucous  membrane  becomes  thin  and  pale,  the  amount  of  hy- 
drochloric acid  is  diminished  and  there  is  probably  some  change 
in  the  character  of  the  peptic  secretions.     In  the  intestines  there 


28  PHYSIOLOGICAL   OLD   AGE 

is  a  waste  of  the  muscle  fibers  and  diminished  secretions.  The 
small  intestines  become  very  thin,  the  large  intestines  are  gener- 
ally dilated,  the  dilatation  about  the  sigmoid  flexure  sometimes 
forming  a  pouch  or  sack,  of  two  or  three  times  its  normal  diam- 
eter. Owing  to  the  impaired  circulation  hemorrhoids  are 
frequently  present.  Atheroma  of  the  nutrient  vessels  causes 
atrophy  of  the  villi,  and  waste  of  muscle  fibers  causes  the  folds 
of  the  valvulae  conniventes  to  be  smoothed  out. 

The  liver  is  contracted  and  harder  than  in  maturity,  the  cells 
are  smaller,  there  is  an  increase  of  connective  tissue  and  owing 
to  lessened  nutrition  the  organ  is  paler  than  in  maturity.  In 
extreme  old  age  its  weight  may  sink  to  800  grams  or  less.  If, 
however,  there  is  impeded  circulation  or  weakened  heart  action 
there  will  be  engorgement.  The  surface  becomes  granular  and 
the  capsule  becomes  cloudy,  thick  and  closely  adherent  to  the 
surface.  The  gall-bladder  becomes  thickened  and  usually 
adheres  to  the  adjacent  portion  of  the  liver.  The  duct  is  thick- 
ened and  its  caliber  is  diminished.  The  bile  is  thicker,  more 
viscid  than  in  maturity  and  contains  a  larger  proportion  of 
cholestrin.  Gall  stones  are  frequently  found.  The  spleen  is 
reduced  in  size,  it  becomes  firm,  the  trabeculse  compress  the 
blood-vessels  causing  them  to  atrophy  and  in  extreme  cases  the 
whole  organ  is  a  mass  of  connective- tissue  fibers  enmeshing 
small  portions  of  spleen  substance.  The  relative  loss  of  weight 
of  the  spleen  is  greater  than  that  of  any  other  organ,  the  spleen 
in  old  age  weighing  less  than  half  as  much  as  in  maturity.  The 
pancreas  atrophies,  there  is  proliferation  with  hardening  of  the 
connective  tissue  compressing  the  vesicles  and  lobules,  the  canal 
of  Wirsung  becomes  hard  and  its  caliber  diminished.  Occasion- 
ally the  organ  undergoes  fatty  degeneration  without  diminution 
in  size.  Its  texture  which  is  in  maturity  rather  soft  becomes 
harder,  of  the  consistency  of  softened  wax.  The  kidneys  un- 
dergo atrophic,  sclerotic  and  other  degenerative  changes  which 
are  so  like  the  pathological  changes  found  in  interstitial  nephritis 
that  it  is  often  impossible  to  distinguish  between  them  at  post- 
mortem examinations.  The  recent  discovery  of  a  progressive 
increase  of  connective-tissue  fibers  between  the  apex  of  the 
pyramids — the  increase  continuing  from  birth  to  death  in 
old  age — is  as  far  as  known  the  only  histological  manifestation 
of  ageing  which  does  not  appear  as  a  pathological  condition. 


ANATOMICAL  CHANGES  IN  OLD  AGE 


29 


The  kidney  in  old  age  has  a  lobulated  appearance,  it  is  granu- 
lar, pale,  and  hard,  the  glomeruli,  loops  and  convoluted  tubes 
atrophy  and  become  sclerosed.  The  connective  tissue  forms 
bands  which  compress  the  parenchyma.  The  capsule  becomes 
thick  and  adheres  closely  to  the  surface.  The  ureters  lose  their 
elasticity  through  waste  of  muscular  fibers  and  the  tubes  become 
dilated.  The  inner  coat  becomes  thickened  but  the  caliber  is 
increased  and  late  in  life  the  ureters  become  stiff  fibrous  tubes. 
The  senile  changes  in  the  bladder  begin  with  a  waste  of  muscular 
fibers  and  a  proliferation  of  connective  tissue.  The  waste  of 
muscle  permits  a  dilatation  of  the  walls  of  the  bladder  while 
the  connective  tissue  forms  bands  in  the  walls  producing  con- 
strictions with  pockets  between  them.  The  sphincter  atrophies 
permitting  dribbling.  Late  in  life  there  is  generally  a  fatty 
degeneration  of  the  bladder.  The  prostate  becomes  enlarged 
in  perhaps  one-third  of  senile  cases  while  atrophy  is  found  in 
less  than  10  per  cent.  The  hypertrophy  is  in  the  muscular 
tissue  and  there  are  often  found  in  the  mass  small  fibrous  tumors 
and  minute  calculi.  Sometimes  there  is  an  increase  of  the  glan- 
dular substance  with  fatty  infiltration.  The  hypertrophy  is 
generally  irregular,  often  only  one  lobe  being  involved.  In 
these  cases  the  favorite  location  is  the  middle  lobe.  When 
there  is  atrophy,  the  changes  are  similar  to  the  changes  in  the 
liver;  there  is  a  proliferation  of  connective  tissue  which  forms 
bands  compressing  the  gland  substance.  The  ducts  are  fre- 
quently blocked  by  a  deposit  of  lime  salts.  The  changes  occur- 
ring in  the  testicle  are  similar  to  the  changes  in  other  secreting 
organs  i.e.,  formation  of  fibrous  tissue  bands  which  compress 
the  glandular  substance  followed  by  atrophy  and  later  sclerosis 
of  the  substance.  The  enveloping  capsule  becomes  thick  and 
closely  adherent.  There  is  a  diminution  in  the  number  of  the 
spermatozoa  but  not  in  their  activity  or  functional  powers.  The 
duct  changes  are  like  the  changes  in  other  secreting  ducts,  de- 
generation and  thickening  of  the  inner  coat,  waste  of  muscular 
and  elastic  fibers,  atrophy  and  sclerosis  of  the  outer  coat.  The 
changes  in  the  female  generative  organs  begin  at  the  menopause 
and  while  really  senile  changes  they  belong  to  the  realm  of  the 
gynecologist. 

The  changes  in  the  brain  are  atrophic  and  degenerative.    The 
waste  is  confined  to  the  cerebrum,  mainly  at  the  cortex  and  most 


30  PHYSIOLOGICAL   OLD   AGE 

frequently  in  the  left  hemisphere.  The  loss  in  weight  is  about 
ioo  grams  at  eighty  years  of  age.  There  is  an  increase  of  fluid,  a 
decrease  of  fat,  the  brain  is  denser,  there  is  white  softening  of  the 
walls  of  the  ventricles,  the  pia  mater  is  thickened,  there  are  pac- 
chionian granulations  and  there  is  an  increased  amount  of  fluid 
in  the  meshes.  The  fissures  are  shallower,  the  cortex  is  thinner 
and  frequently  contains  amyloid  bodies  while  connective-tissue 
fibers  are  increased.  The  nerve  fibers  are  thinner,  the  cells  are 
atrophied.  In  many  cases  minute  cavities  form  around  lymph 
vessels.  These  cavities  called  ' '  Etat  Crible, ' '  formerly  supposed 
to  be  perivascular  spaces,  are  retractions  of  brain  substance  due 
to  waste.  Sometimes  spots  of  miliary  aneurysm  and  softening 
are  found.  Atheromatous  changes  in  the  vessels  of  the  brain 
are  more  pronounced  than  in  any  other  organ  of  the  body. 
The  changes  in  the  cord  are  similar  to  the  changes  in  the  brain. 
Amyloid  bodies  are  frequently  found  around  the  central  canal, 
there  is  a  waste  of  the  ganglion  cells  of  the  anterior  horns, 
pyramids  and  posterior  fibers.  There  is  a  general  decrease  in 
volume  of  nervous  tissue,  an  increase  of  cerebrospinal  fluid, 
the  cord  is  darker  and  more  firm,  the  meninges  are  thickened, 
cloudy  and  sometimes  contain  osseous  plates.  The  athero- 
matous arteries  present  a  beaded  appearance,  and  there  are 
often  spots  of  miliary  aneurysm,  hemorrhage  and  softening. 
Occasionally  zones  of  sclerosis  are  found  around  the  blood-vessels, 
which  press  upon  the  nerves  causing  them  to  waste.  The 
changes  in  the  nerves  are  probably  similar  to  the  changes  in 
the  cord  but  these  changes  come  on  late  and  the  functional 
changes  in  the  organs  usually  terminate  life  before  changes  in 
the  nerves  are  far  advanced.  In  the  peripheral  nerves  parenchy- 
matous degeneration  takes  place  in  the  terminals  and  terminal 
fibers  and  proceed  toward  the  center. 

The  senile  changes  in  the  eye  are  sclerosis  of  the  lens  and 
weakening  of  the  muscles  of  accommodation;  in  the  ear  there 
is  waste  of  the  drum  and  a  change  in  the  auditory  nerves;  in 
the  nose  there  is  atrophy  of  the  Schneiderian  membrane.  The 
changes  in  the  tactile  ends  are  not  well  known,  but  it  is  evi- 
dent that  some  change  occurs  as  there  are  great  functional 
changes.  Neither  is  it  known  what  changes  occur  in  the  taste 
bulbs. 


PHYSIOLOGICAL   CHANGES   IN   OLD   AGE  3 1 

PHYSIOLOGICAL  CHANGES  IN  OLD  AGE 

The  changes  in  physiological  functions  in  old  age  are  due 
either  to  the  anatomical  changes  or  to  some  causes  for  which  we 
can  find  no  anatomical  change  and  we  therefore  call  them  purely- 
functional  manifestations.  Many  functional  changes  begin 
before  anatomical  changes  can  be  demonstrated  and  in  the 
nervous  system  profound  alteration  of  function  may  persist 
throughout  life,  yet  postmortem  examination  does  not  disclose 
any  change  in  the  tissues.  There  is  no  relationship  between  the 
extent  of  anatomical  and  functional  change  in  old  age  even  in 
pathological  conditions.  Neither  do  the  objective  or  subjective 
manifestations  give  any  clue  to  the  extent  or  character  of  the 
anatomical  or  physiological  changes.  The  earliest  functional 
change  is  diminished  activity,  diminished  power  and  lessened 
vital  resistance  to  deleterious  influences.  Diminished  activity 
is  evidenced  by  diminished  metabolism;  lessened  elimination  of 
CO2.  Diminished  power  is  evidenced  by  more  rapid  fatigue  or 
by  a  greater  effort  required  to  do  laborious  work.  This  is  due  to 
weakening  of  muscle  fibers.  Lessened  vital  resistance  is  evident 
from  the  greater  liability  to  certain  diseases,  tardy  recovery, 
slow  healing  of  wounds,  and  the  frequency  of  sequelae. 

Omitting  the  functional  changes  due  to  progressive  pro- 
liferation of  the  connective-tissue  fibers  between  the  pyramids 
of  the  kidneys  and  those  early  cases  of  arteriosclerosis  and 
cardiac  hypertrophy  which  are  due  to  excessive  muscular  activity, 
fast  living,  syphilis  and  other  controllable  causes,  the  earliest 
functional  change  occurs  in  the  lungs.  Until  the  limit  of 
growth  has  been  reached  the  continual  deposit  of  dust  in  the 
bronchioles  does  not  impair  the  respiration.  Afterward  this 
deposit  diminishes  the  caliber  of  the  tubes  and  the  amount  of 
tidal  air  is  consequently  diminished.  Aeration  of  the  blood 
is  now  incomplete  and  from  this  time  forward  the  imperfectly 
oxygenated  blood  has  a  progressively  lessened  capacity  for 
carrying  nutrition  to  the  organs  and  tissues  and  carrying  off 
waste.  As  this  is  one  of  the  fundamental  causes  of  ageing, 
it  will  be  discussed  under  that  heading.  The  compression  of 
the  lungs  and  their  diminished  expansibility  cause  shallow 
breathing.  The  vital  capacity  is  diminished  at  the  rate  of  about 
1  1/2  cubic  inches  per  annum  and  the  amount  of  C02  expired 


32  PHYSIOLOGICAL   OLD   AGE 

which  in  maturity  is  about  1340  cubic  inches  per  hour  falls  to 
less  than  1000  cubic  inches  between  the  ages  of  sixty  and  eighty, 
and  may  fall  to  less  than  700  cubic  inches  in  extreme  old  age. 
The  respirations  are  increased  in  frequency,  there  is  generally 
shortness  of  breath,  dyspnea  is  easily  induced,  the  respiratory 
motion  is  confined  to  the  upper  part  of  the  chest,  the  motion 
being  up  and  down  and  not  expansive.  Wheezing  and  persist- 
ent dyspnea  are  indications  of  advanced  emphysema. 

The  functional  changes  in  the  circulatory  system  sometimes 
correspond  with  the  anatomical  changes,  occasionally  there  are 
marked  perversions  of  function  which  cannot  be  explained  by 
the  changes  that  are  found,  and  at  times  physical  examination 
reveals  anatomical  and  functional  changes  that  give  no  objective 
or  subjective  symptoms. 

There  is  high  blood  pressure  as  long  as  the  heart  can  maintain 
the  circulation  through  a  compensatory  hypertrophy.  When 
the  demands  upon  the  heart  are  greater  than  it  can  respond  to, 
the  blood  pressure  falls  below  normal.  It  may  also  fall  through 
dilatation  of  the  arterioles  and  when  the  blood  supply  to  the 
left  ventricle  is  deficient.  The  thickening  of  the  aortic  valve 
and  the  enlargement  of  the  aortic  orifice  cause  an  insufficiency 
of  the  valve  with  the  consequent  regurgitation.  This  weakens 
the  mitral  valve  and  may  cause  either  rupture  of  that  valve  or 
contraction  of  the  cusps  which  are  already  thickened  through 
extension  of  the  senile  endocarditis,  and  mitral  insufficiency  is 
produced.  The  aorta  is  generally  dilated  and  its  elasticity  is 
diminished.  These  changes  cause  a  delay  in  the  propul- 
sion of  blood  and  the  current  is  slowed,  the  pulse  being 
normally  slower  in  old  age,  ranging  from  65  to  75  a  minute 
in  the  male,  and  from  5  to  10  beats  more  in  the  female. 
Slight  influences,  however,  tend  to  increase  or  diminish  the 
pulse  rate  and  permanent  bradycardia  is  not  infrequent.  The 
pulse  in  senility  is  no  indication  of  the  condition  of  the  heart  as 
its  strength,  frequency  and  regularity  may  be  influenced  by 
factors  outside  of  that  organ.  Irregularity  in  strength  and 
rhythm  may  exist  in  the  heart  without  any  degeneration  of  the 
heart  muscle,  the  fault  in  such  cases  being  in  the  nervous 
regulation.  The  heart  sounds  are  somewhat  altered,  the  first 
sound  being  rough  and  prolonged  and  the  second  sound  louder 
than  in  maturity.     There  is  occasionally  a  reduplication  of  the 


PHYSIOLOGICAL   CHANGES   IN    OLD   AGE  33 

first  sound  due  either  to  irregular  contraction  of  the  ventricles 
or  to  mitral  and  tricuspid  changes.  There  is  generally  an  aortic 
bruit  also  various  valvular  murmurs  which  will  be  described  under 
the  valvular  diseases.  The  blood  current  is  slackened  and  owing 
to  the  contracted  vessels  the  amount  of  blood  in  the  arteries  is 
diminished.  As  the  changes  in  the  lungs  prevent  complete 
aeration  of  blood  the  character  of  the  blood  is  changed  and  it 
passes  through  the  capillaries  with  difficulty.  The  vis-a-tergo 
being  thus  weakened  and  the  vis-a-fronte  being  reduced  through 
the  changes  in  the  right  heart  and  lessened  respiratory  move- 
ments, the  veins  become  filled  with  a  slow-moving  current  of 
blood  producing  venosity  and  varix. 

Investigations  into  the  blood  changes  in  old  age  give  con- 
tradictory results  and  lead  to  uncertain  conclusions.  In  a 
series  of  twelve  fairly  healthy  individuals  over  seventy  years  of 
age  reported  by  Grawitz,  the  blood  count  showed  red  cells  from 
three  millions  to  over  five  and  a  half  millions;  white  cells,  from 
4000  to  8000;  hemoglobin  from  90  to  no  per  cent.;  S.G.  from 
1048  to  1060. 

The  particular  ingredients  which  are  used  up  in  the  nutrition 
of  the  tissues,  and  the  method  of  conversion  are  unknown.  It  is 
certain  that  repair  of  waste  is  made  up  from  the  serum  and  that 
the  red  cells  furnish  the  oxygen  required  in  the  process  of 
metabolism,  but  neither  the  microscope  nor  chemical  analysis 
has  revealed  how  the  changes  are  effected.  The  simple  fact 
that  chemical  processes  in  the  body  do  not  correspond  with 
chemical  processes  outside  of  the  body  would  indicate  that  there 
is  a  vital  factor  which  modifies  the  organic  processes.  Food 
subjected  in  a  test-tube  to  the  same  enzymes  that  are  found  in 
the  stomach  does  not  undergo  the  same  change  as  occurs  in  the 
stomach.     The  character  of  this  vital  factor  is  not  known. 

With  the  single  exception  of  the  proliferation  of  connective- 
tissue  cells  between  the  apex  of  the  pyramids,  the  anatomical 
changes  in  the  kidneys  show  no  difference  under  the  microscope 
from  the  kidneys  of  interstitial  nephritis,  but  there  is  a  great 
difference  in  the  performance  of  the  functions.  In  old  age  the 
amount  of  urine  is  diminished,  it  is  of  lower  specific  gravity  and 
contains  less  solids  than  in  maturity,  the  amount  of  urea  is 
considerably  lessened  and  may  not  exceed  125  grains  per  day, 
while  the  amount  of  uric  acid  is  reduced  by  about  half.  There 
3 


34  PHYSIOLOGICAL    OLD   AGE 

is  occasionally  albuminuria  which  has,  however,  little  significance 
unless  associated  with  casts.  When  the  urine  is  alkaline 
immediately  after  voiding,  it  is  probably  due  to  retention  in 
a  dilated  bladder.  A  dilated  bladder  will  hold  urine  in  the 
pouches — formed  by  the  contraction  of  the  muscle  and  con- 
nective-tissue fibers  in  the  walls — for  days;  the  urine  decomposes 
and  ammonia  is  produced.  The  physiological  changes  in  the 
digestive  organs  are  due  partly  to  the  changes  in  the  organs 
involved,  partly  to  the  changed  power  of  assimilation  and 
partly  to  the  food.  With  the  falling  out  of  the  teeth  solid  food 
cannot  be  masticated  properly  nor  thoroughly  mixed  with  saliva. 
Such  food  is  swallowed  in  pieces,  only  the  outside  being  acted 
upon  by  the  saliva  and  excessive  work  is  put  upon  the  gastric 
secretions  which  are  already  diminished  in  quantity  and  probably 
changed  in  quality.  Solid  food  is  not  absorbed  unless  thoroughly 
disintegrated  and  easily  soluble.  Consequently  food,  unless 
introduced  into  the  stomach  in  such  form  as  to  be  readily  ab- 
sorbed, remains  there  for  hours,  perhaps  days,  decomposing 
or  undergoing  fermentation  or  it  passes  into  the  intestines 
unchanged  giving  the  intestinal  secretions  excessive  work. 

The  sense  of  taste  is  obtunded,  and  the  muscles  of  deglutition 
are  weakened  so  that  it  requires  a  sensible  effort  to  swallow. 
Owing  to  the  anatomical  changes  in  the  stomach  the  gastric 
digestion  is  slowed  and  imperfectly  performed.  While  the 
dilatation  of  the  stomach  and  the  waste  of  the  muscular  coat 
with  the  atrophy  of  the  glands  lessen  the  activity  of  the  organ 
and  food  remains  longer  in  the  stomach  than  in  maturity, 
weakening  and  waste  of  the  muscular  structure  of  the  pylorus 
permits  food  particles  to  pass  into  the  duodenum  unchanged 
and  such  particles  may  pass  through  the  intestines  undigested. 
The  rate  of  digestion  in  the  stomach  in  old  age  is  much  slower 
than  the  rate  of  digestion  in  maturity. 

The  most  pronounced  functional  changes  in  the  intestines 
are  constipation,  occasional  diarrhea,  and  an  excessive  accumu- 
lation of  feces  in  the  colonic  pouch.  The  first  of  these  changes 
is  due  to  the  weakening  and  waste  of  muscle  fibers  whereby 
peristaltic  activity  is  diminished.  This  is  frequently  accompa- 
nied by  neglect  of  the  aged  to  attend  the  call  for  evacuation  of 
the  bowel,  and  this  last  is  the  main  cause  of  the  dilatation  of  the 
colon  and  rectum,  whereby  pouches  are  formed.      Here  we  see 


Ossification  of  subscapalaris  tendon.     Waste  of  bursa.     (Courtesy  of  S.  Epstein, 

M.  D.,  New  York.) 


PHYSIOLOGICAL   CHANGES   IN    OLD   AGE 


35 


one  of  the  many  vicious  circles  which  are  formed  in  old  age. 
The  diminished  elasticity  of  muscle  fibers  permits  dilatation  of 
the  gut  which  consequently  becomes  filled  with  fecal  matter 
distending  the  bowel,  this  distention  further  stretching  the 
fibers  and  impairing  their  elasticity.  Senile  diarrhea,  while 
due  to  the  intestinal  changes,  is  really  caused  in  most  cases  by 
improper  feeding,  the  food  being  taken  in  too  short  intervals, 
in  excessive  amount,  or  by  entering  the  intestines  unchanged  it 
acts  as  an  irritant. 

Functional  changes  in  the  brain  and  nervous  system  are  often 
the  most  marked  of  all  the  changes  that  occur  in  the  organism 
and  in  many  cases  there  is  no  corresponding  anatomical  change. 
Lessened  coordination,  slowed  afferent  and  efferent  impulses, 
weakened  and  often  perverted  sensibility,  impaired  activity  of 
the  regulating  centers  and  various  forms  of  mental  disturbance 
may  be  present,  yet  no  morphological  change  can  be  found  to 
account  for  them.  These  are  called  senile  neuroses.  Some  of 
the  functional  changes  in  the  aged  resemble  the  perverted 
activities  associated  with  disease  in  maturity.  Senile  tremor 
simulates  paralysis  agitans  but  the  central  canal  of  the  cord  may 
not  be  encroached  upon  as  is  the  case  in  the  diseased  condition. 
On  the  other  hand,  extensive  anatomical  changes  have  been 
found  without  functional  changes.  Bunsen,  who  died  at  the 
age  of  eighty-nine,  was  engaged  in  profound  scientific  research 
up  to  the  time  of  his  death,  yet  his  brain  was  greatly  atrophied. 
The  same  condition  was  found  in  the  brain  of  Mommsen,  the 
great  German  historian. 

Among  the  earliest  of  the  functional  changes  in  the  nervous 
system  are  delayed  and  weakened  impulses.  Action  does  not 
respond  as  rapidly  to  the  will,  and  it  requires  a  greater  motor 
impulse  to  perform  the  act  while  greater  mental  concentration 
is  required  to  obtain  and  hold  sensory  impressions.  Brain  fag 
sets  in  more  rapidly  than  in  maturity  and  while  the  quality  of 
the  work  may  not  deteriorate,  the  amount  of  work  that  can  be 
done  at  a  time  is  less.  Aged  writers  who  could  write  for  ten  or 
twelve  hours  without  intermission  during  maturity  must  now 
take  frequent  rests  else  brain  fag,  then  mental  confusion  and 
finally  complete  mental  exhaustion  set  in.  The  rest  must  be 
either  in  the  form  of  sleep  or  of  some  diversion  which  requires 
no  mental  exertion.  When  an  old  man  falls  asleep  during  a 
sermon  or  lecture,  it  is  not  through  lack  of  interest  but  from 


36  PHYSIOLOGICAL   OLD   AGE 

brain  fatigue  following  concentrated  interest.  Tendon  reflexes 
are  generally  diminished.  Ferris  and  Bosco  found  the  knee 
reflex  absent  in  20  per  cent.,  arm  reflex  absent  in  71  per  cent.,  and 
foot  reflex  in  81  per  cent,  of  cases  between  sixty-five  and  eighty- 
five  years  of  age.  In  over  30  per  cent.,  however,  the  knee  reflex 
was  exaggerated  due  probably  to  waste  of  fibers  in  the  pyramids. 
Sometimes  the  exaggerated  tendon  reflex  is  associated  with 
tremor  and  a  pronounced  uncertain  gait,  the  whole  simulating 
cerebrospinal  sclerosis.  In  such  cases  arteriosclerosis  of  the 
brain  and  cord  are  usually  found  and  often  cerebral  softening. 

The  functions  of  the  sensory  organs  are  impaired  in  old  age. 
The  sclerosis  and  flattening  of  the  crystalline  lens  render  accom- 
modation for  near  objects  difficult  and  presbyopia  is  produced. 
Where  there  has  been  a  myopia  in  earlier  life  it  frequently 
happens  that  the  senile  flattening  of  the  lens  will  so  far  reduce 
the  former  excessive  convexity  as  to  bring  about  a  normal  con- 
vexity of  the  emmetropic  eye.  This  explains  the  so-called 
"second  sight"  of  aged  persons  who  had  been  obliged  to  use 
glasses  in  earlier  life  and  can  see  well  without  glasses  in  old  age. 
The  term  "second  sight"  is  also  applied  to  a  myopie  condition 
that  occurs  in  incipient  cataract  in  the  aged  who  have  presby- 
opia or  hypermetropia,  seeing  well  at  a  distance  but  requiring 
convex  lenses  for  reading.  A  swelling  of  the  lens  and  an  in- 
crease in  its  density  during  the  formation  of  the  cataract  in- 
creases the  refraction  and  the  individual  can  now  read  without 
glasses  but  distance  vision  is  impaired.  The  acuteness  of  vision 
is  however  not  restored,  but  there  is  an  increasing  blurring  and 
dimness  depending  upon  the  site,  distribution  and  degree  of 
opacity.  Though  rather  frequent  in  the  aged  it  is  pathological. 
Weakened  accommodation  of  the  muscles  interferes  with  motion 
of  the  organ.  Owing  to  the  weakening  of  the  muscular  fibers  of 
the  iris  the  pupils  respond  slowly  to  light,  and  are  generally 
contracted. 

The  arcus  senilis  which  is  always  found  in  the  aged  does  not 
interfere  with  sight  nor  does  it  denote  fatty  degeneration  of  the 
heart  as  was  formerly  thought.  (The  author  has  a  well-marked 
arcus  senilis  which  was  shown  to  the  class  during  his  school  days.) 

Presbyacusia  (deafness)  is  generally  present  in  old  age  and  in 
many  cases  the  loss  of  hearing  is  complete.  This  is  due  to  some 
change  in  the  auditory  nerve.  The  sense  of  smell  is  generally 
weakened  and  often  obliterated.     This  is  due  either  to  the  waste 


PHYSIOLOGICAL   CHANGES   IN   OLD   AGE  37 

of  the  Schneiderian  membrane  or  it  may  be  due  to  atrophy  of  the 
olfactory  nerve  or  to  a  change  in  the  olfactory  bulb.  There  may 
be  perversions  of  smell  for  which  no  explanation  can  be  found. 

The  sense  of  taste  is  obtunded  and  occasionally  perverted. 
While  the  sense  of  smell  and  the  sense  of  taste  probably  become 
weakened  through  morphological  changes  in  the  nerves  or  end 
organs,  the  perversions  are  probably  psychoses.  Sensation  is 
impaired  in  several  ways.  There  may  be  anesthesia,  hyper- 
esthesia and  various  paresthesias.  These  changes  are  due  to 
the  changes  in  the  skin  and  terminals  of  the  nerves.  The  aged 
generally  feel  cold.  This  is  due  to  lessened  surface  circulation 
and  impairment  of  the  heat  regulation.  The  weakened  tactile 
sense  is  due  to  the  degeneration  of  the  tactile  end  organs. 
Lessened  skin  sensibility,  anesthesia,  is  due  partly  to  the  mental 
weakness,  the  mind  failing  to  note  skin  sensations  unless  it  is 
concentrated  upon  the  impression  received,  and  partly  to  the 
nerve  changes.  Hyperesthesia  is  due  to  nerve  changes.  The 
paresthesias  such  as  numbness,  formication,  itching,  etc.,  may 
be  psychic,  organic,  or  both. 

It  is  not  always  easy  to  say  how  far  mental  deviations  are 
natural  and  normal  in  old  age  and  where  perversion  begins. 
Lessened  capacity  for  work  is  an  early  manifestation  of  senile 
atrophy  of  the  brain.  In  some  this  lessened  capacity  is  shown  in 
rapid  fatigue,  in  some  the  quality  of  the  work  is  impaired,  in 
others  it  is  forgetfulness.  If  one  is  a  writer  he  finds  that  new 
ideas  do  not  come  as  readily  to  his  mind  as  formerly;  that  he 
must  debate  over  the  choice  of  words,  that  he  must  make 
corrections  frequently,  while  formerly  he  could  write  pages  with- 
out a  change.  If  he  is  a  reader  he  finds  that  he  does  not  grasp 
the  substance  of  his  reading  readily  and  that  he  must  frequently 
read  a  paragraph  several  times  if  he  wants  to  digest  its  import. 
He  finds  it  more  difficult  to  concentrate  his  attention  and  after 
reading  a  few  pages  he  wants  to  take  up  some  other  work. 
Where  formerly  a  single  reading  left  a  clear  impression  on  his 
mind  to  be  reproduced  at  will,  now  the  impression  soon  fades 
and  an  effort  is  required  to  reproduce  it.  His  interest  in  general 
affairs  wanes  but  the  interest  in  a  hobby  may  remain  unim- 
paired or  may  even  be  increased  as  his  interest  in  other  direc- 
tions lessens.  He  may  in  this  way  show  greater  mental  capacity, 
greater  reasoning  power  than  before,  but  it  is  all  exerted  in  one 
direction.     The  mind  is  accustomed  to  activity  in  many  fields. 


38  PHYSIOLOGICAL    OLD    AGE 

If  all  its  efforts  are  directed  into  one  channel  it  will  do  more  work 
in  this  one  channel,  even  though  its  total  capacity  for  work  is 
diminished.  It  is  simply  the  principle  of  economic  specializa- 
tion applied  to  the  mind.  This  will  explain  the  remarkable 
works  turned  out  by  great  men  in  all  fields  in  their  old  age. 
Where  there  is  general  mental  decay,  the  will,  sensations, 
intellect  and  emotions  become  less  active,  the  weakening  being 
progressive  until  complete  dementia  is  reached,  and  the  individ- 
ual's existence  is  like  that  of  the  absolute  idiot.  In  these  ex- 
treme cases,  however,  there  is  usually  pathological  cerebral 
softening.  The  change  in  temperament  which  is  often  marked 
in  old  age  is  not  a  senile  psychosis  though  generally  classed 
among  the  senile  psychic  changes.  It  seems  to  me  that  it  is  the 
natural  result  of  the  realization  of  advancing  age  with  diminished 
powers,  lessened  opportunities,  increasing  discomforts,  and  the 
fast  approaching  termination  of  life.  Similar  temperamental 
changes  are  observed  in  the  young  when  they  find  that  they  are 
suffering  from  a  fatal  disease.  The  moment  a  man  becomes  a 
grandfather,  though  he  be  but  forty,  he  begins  to  feel  old  and 
changes  in  his  temperament  and  demeanor  can  be  noted.  Other 
causes  such  as  a  sudden  fright,  a  secret  fear,  a  great  loss,  will  do 
the  same.  Owing  to  the  weakened  intellect  in  old  age  the 
individual  loses  control  over  the  emotions,  weakened  memory, 
especially  for  recent  events,  makes  him  more  conscious  of  the 
old  order  of  things,  he  becomes  "old  fashioned,"  holding  on  to 
ancient  ideas  and  methods,  and  becomes  irritated  when  these 
are  displaced.  These  idiosyncrasies  become  obnoxious  to  the 
younger  generation  and  they  look  upon  him  as  queer.  The 
idiosyncrasies  become  more  pronounced  when  the  old  man 
grows  careless  about  his  person  and  his  surroundings,  although 
this  is  mainly  due  to  his  desire  to  avoid  everything  that  may 
cause  physical  exertion.  Even  among  old  women  who  were 
formerly  extremely  neat  this  carelessness  about  their  sur- 
roundings is  often  noticed.  Owing  to  their  innate  vanity  they 
may,  however,  present  an  appearance  of  neatness  though  often 
this  applies  only  to  externals.  Among  the  depressing  influences 
of  early  senility  is  diminution  of  the  sexual  powers  without 
diminished  desire.  Where  desire  and  power  diminish  together 
this  is  not  noticed,  but  the  loss  of  the  power  alone  often  leads  to 
the  sexual  perversions  of  the  exhibitionists.  Mental  weakness 
produces  an  expression  of  apathy;  in  mental  depression  there  is 


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V 


CAUSES    OF   AGEING 


39 


moroseness,  irritability,  often  pre-occupation  (day  dreaming), 
the  individual  talks  to  himself,  sometimes  exhibiting  anger  or 
fear  upon  the  slightest  provocation  or  without  any  apparent 
reason.  (The  changes  during  the  senile  climacteric  have  been 
described  in  the  chapter  on  The  Senile  State.) 

CAUSES  OF  AGEING 

The  question  why  we  grow  old,  or  rather  why,  after  a  period 
of  physical  perfection  the  organs  and  tissues  degenerate  and  their 
functions  become  weakened  and  perverted  until  they  are  unable 
to  maintain  the  harmonious  interrelations  necessary  for  life,  is 
part  of  the  great  problem  of  life  and  death.  Natural  phenomena 
require  scientific  explanations.  Recourse  to  unnatural,  super- 
natural and  superhuman  agencies,  a  belief  which  can  only  be 
based  on  faith,  is  simply  an  evasion  of  a  scientific  explanation. 
Of  the  metaphysical  trinity — the  beginning,  life  and  the  here- 
after, life  is  the  one  which  is  tangible  to  the  extent  that  its 
manifestations  may  be  studied.  The  nature  of  the  force  which 
we  call  vitality  is  unknown,  but  we  cannot  say  that  it  is  unknow- 
able. A  scientific  theory  of  life  must  have  a  comprehensible 
basis  though  we  may  not  be  able  to  prove  the  theory  or  the 
existence  of  the  basis,  with  our  present  methods  of  investigation. 
When  we  fall  back  upon  *  'the  will  of  God"  or  "fate"  or  "nature" 
as  our  explanation  of  life  and  its  manifestations,  we  accept  the 
basis  on  faith  and  not  on  fact  or  reason.  We  know  that  life 
depends  upon  the  existence  in  the  protoplasm  of  a  property 
called  irritability.  When  that  property  is  absent  the  protoplasm 
is  only  a  highly  complex  chemical  which  we  have  not  yet  succeeded 
in  making  synthetically.  Ageing  is  a  manifestation  of  life. 
It  is  found  throughout  the  animal  and  vegetable  kingdom;  trees 
show  the  effects  of  age  and  even  among  the  infusoria  there  are 
changes  which  result  in  their  death  and  which  are  considered  to 
be  senile  degenerations.  Many  theories  have  been  advanceol 
to  account  for  this  ageing.  The  old  idea  that  the  body  becomes 
worn  out  like  an  old  engine  and  the  tissue  wastes  just  as  the 
material  wears  away  in  machinery  or  goods,  is  a  fanciful  simile 
without  a  basis  of  fact.  There  is  no  similarity  between  the 
wear  and  tear  of  material  through  friction  or  by  the  elements 
and  the  waste  of  tissue,  except  in  the  wear  of  the  epidermis. 
Neither  does  the  body  become  worn  out  through  activity,  indeed 
in  the  early  period  of  life  activity  hastens  repair  and  growth. 


40  PHYSIOLOGICAL   OLD   AGE 

There  is  no  analogy  between  the  metabolic  processes  and  the 
wear  and  repair  of  inanimate  things.     Organs  and  tissues  that 
are  rarely  or  never  used  in  one  individual  undergo  the  same 
degenerative  changes  that  occur  where  they  have  been  actively 
employed  in  another.     The  virgin  uterus  undergoes  the  same 
change  at  the  menopause  that  occurs  in  the  uterus  of  the  multipara. 
The  brain  of  the  absolute  idiot  shows  in  advanced  age  the  same 
changes  that  go  on  in  the  brain  of  the  sage.     In  old  age  repair  is 
not  as  active  as  in  youth  and  excessive  activity  hastens  waste, 
but  this  is  the  result  and  not  the  cause  of  the  senile  changes. 
There   are  two  prominent   histo-mechanical  theories;   that  of 
Demange  and  the  more  recent  theory  of  Thoma.     Demange 
ascribed  the  cause  of  the  senile  changes  "to  a  change  in  the 
quantity  and  quality  of  the  interstitial  nutritive  material  due 
to  changes  in  the  circulation  and  this  is  due  to  atheroma  and 
arteriosclerosis. ' '    Tracing  back  the  cause  of  the  vascular  changes 
he  believed  that  the  constant  friction  of  the  blood  against  the 
inner  coat  of  the  vasa  vasorum  irritated  the  endothelium,  this 
persistent  irritation  producing  an  endarteritis,  with  thickening 
of  the  inner  coat  and  consequent  diminished  caliber  of  the  fine 
vessels.     The  supply  of  nutrition  to  the  larger  vessels  being  thus 
diminished  they  begin  to  degenerate  through  fatty  infiltration 
and  production  of  atheroma.     The  subsequent  senile  changes  are 
due  to  diminished  nutrition  following  diminished  caliber  of  the 
nutrient  vessels.     This  theory  followed  the  work  of  H.  Martin 
on  the  pathogenesis  of  atheroma.     Martin  found  cases  of  ob- 
literating endarteritis  of  the  vasa  vasorum  followed  by  a  necrobi- 
otic  infarct  in  the  larger  vessel.     The  affected  cells  excite  further 
irritation  in  the  surrounding  tissue  of  the  vessels,  producing  vari- 
ous forms  of  degeneration,  thereby  interfering  with  the  circula- 
tion through  them.     Thoma  believes  "that  the  ceaseless  activity 
of  the  heart  and  blood-vessels  gradually  weakens   the   elastic 
fibers  of  the  vessels  as  would  happen  in  a  piece  of  rubber  which  is 
expanded  and  contracted  with  ceaseless  regularity.     The  loss  of 
tone  thus  occasioned  permits  a  dilatation  of  the  vessels,  the 
circulation    is    slackened    partly    through    the    dilatation    and 
partly  through  the  lessened  contractility  of  the  vessels  and  the 
nutrition  of  the  organism  is  thus  impaired."     There  are  several 
other   theories   giving   nutritional   changes   following  vascular 
changes  (atheroma  and  arteriosclerosis)  as  the  cause  of  ageing, 


CAUSES   OF   AGEING  4I 

differing,  however,  from  Demange  as  to  the  cause  of  the  arterial 
degeneration.  The  principal  objection  to  the  theories  which 
charge  the  senile  changes  to  arteriosclerosis  is  that  arterio- 
sclerosis occurring  in  maturity  in  connection  with  other  diseases 
and  even  without  any  other  pathological  condition  is  not 
followed  by  such  changes  as  occur  in  old  age.  Another  class 
of  theories  is  based  upon  the  assumption  of  the  existence  of  a 
vital  principle.  This  assumption  has  no  demonstrable  basis. 
If  there  is  a  concrete  something,  which  is  the  essence  of  life  and 
which  causes  all  the  changes  that  constitute  life,  we  can  form  no 
conception  of  its  character.  If  we  say  it  is  the  soul  we  have 
again  an  inexplicable,  intangible,  immaterial  something  not 
susceptible  of  scientific  proof.  Vitality  itself  may  be  a  form  of 
energy  not  bound  by  the  physical  laws  with  which  we  are 
familiar,  since  no  other  form  of  energy  can  be  converted  into  it, 
and  it  is  subject  to  final  extinction.  This,  however,  does  not 
justify  the  assumption  of  a  vital  principle,  nor  is  there  any  other 
scientific  basis  for  such  assumption.  Durand-Fardel's  theory 
was  based  upon  the  existence  of  a  vital  principle  of  limited 
duration.  He  believed  that  in  animal  life,  as  in  some  forms  of 
plant  life,  when  the  organism  had  completed  its  purpose  to 
reproduce  the  species  and  thus  perpetuate  the  race,  there  was 
no  further  object  in  its  existence. 

After  the  menopause  in  woman  and  the  critical  period  of  man, 
heteroplastic  processes  take  the  place  of  the  normal  anabolic 
processes  and  these  lead  to  such  changes  in  the  functions  that 
their  harmonious  interaction  is  impossible  and  death  results. 
It  is  hardly  necessary  to  show  the  fallacy  of  this  theory  since 
physical  life  is  not  dependent  upon  sexual  activity.  The  most 
prominent  theory  of  ageing  to-day  is  Metchnikoff's  theory  or 
rather  theories,  of  tissue  phagocytosis  and  autointoxication 
through  the  absorption  of  the  products  of  intestinal  decomposi- 
tion. The  theory  that  the  waste  of  tissue  in  advanced  age  is 
due  to  the  destruction  of  the  tissue  cells  by  macrophages  has 
been  criticized  on  the  ground  that  in  many  tissues  where  there 
is  extensive  waste  no  macrophages  are  found  and  the  waste  can 
be  explained  by  insufficient  nutrition.  Even  in  the  brain 
where  Metchnikoff  demonstrated  the  presence  of  neurophages  in 
the  aged,  atrophy  has  been  found  without  neurophages.  The 
theory  of  autointoxication  through  the  absorption  of  ptomaines 
and  other  toxic  material  from  the  intestines,  which  the  organism 


42  PHYSIOLOGICAL   OLD   AGE 

is  unable  to  eliminate,  is  even  less  tenable.  While  such  absorp- 
tion undoubtedly  takes  place  in  old  age  it  also  occurs  in  maturity 
and  youth,  without  producing  senile  changes.  Defective 
elimination  of  leucomaines  and  other  waste  products  of  meta- 
bolism has  been  given  as  a  cause  of  ageing  but  the  criticism 
applied  to  the  autointoxication  theory  of  Metchnikoff,  applies  to 
this.  A  discussion  of  all  the  theories  and  the  many  theoretical 
and  practical  objections  to  them  would  carry  us  beyond  the 
purpose  of  this  work.  Some  theories  are  based  upon  some 
change  in  the  character  or  composition  of  the  blood,  yet  there  is 
no  uniformity  in  the  changes  of  the  blood  in  old  age.  A  recent 
theory  of  this  nature  is  based  upon  unstable  metabolism.  This 
causes  a  change  in  the  blood  salts  and  a  consequent  abnormal 
diosmosis,  which  impairs  the  circulation.  The  changes  in  the 
blood  irritate  the  lining  of  the  blood-vessels  causing  arterio- 
sclerosis, which  further  interferes  with  the  circulation  and  the 
nutrition  of  the  organs  and  tissues. 

Sir  Victor  Horsley's  theory  that  ageing  is  due  to  degeneration 
of  the  thyroid  gland,  and  Lorand's  elaboration  of  that  theory 
including  other  ductless  glands,  do  not  give  us  the  cause  for  the 
senile  degeneration  of  these  glands  and  ageing  may  occur 
without  demonstrable  changes  in  these  glands. 

Naunyn  presents  a  double  theory,  waste  and  wear  of  tissue 
during  activity,  which  is  not  fully  repaired,  and  weakening  of  the 
heat-regulating  centers.  He  points  out  the  deficiency  in  the 
organism  to  repair  the  loss  of  elasticity  in  the  arteries  caused 
by  activity,  and  sees  therein  a  general  fault  in  the  organism  to 
make  good  the  losses  occasioned  by  activity.  The  virgin  uterus 
at  the  menopause  and  the  brain  of  the  idiot  in  old  age  dispose  of 
that  part  of  his  theory.  He  also  says  that  the  local  loss  of  heat 
from  the  surface  causes  general  loss  of  heat.  In  maturity  this 
loss  is  replaced  through  muscular  activity,  and  this  in  turn  creates 
the  necessity  for  food  to  replace  the  waste  of  muscle.  In 
senility  the  heat  regulation  is  weakened  and  the  loss  of  local  heat 
does  not  arouse  the  same  necessity  for  muscular  activity  nor  is 
there  the  same  desire  for  food.  Lessened  food  produces  lessened 
nutrition  to  repair  waste  and  less  fuel  for  combustion.  The 
objection  to  this  theory  is  that  lessened  muscular  activity  is  due 
to  the  anatomical  changes  in  muscles  and  joints  making  motion 
more  difficult,  and  that  the  desire  for  food,  though  stimulated  by 
muscular  activity,  exists  without  the  necessity  for  such  stimu- 


Colonic  Pouch.  (From  Tyson  and  Fussell's  "Practice  of  Medicine.")  Pho- 
tograph of  colonic  dilatation  in  a  young  man.  Used  here  to  illustrate  the  senile 
colonic  pouch,  which  it  resembles. 


CAUSES    OF   AGEING  43 

lation  as  is  seen  in  the  paralyzed  person,  while  forced  feeding  in 
old  age  does  not  increase  the  repair  of  waste.  The  slightly 
lower  temperature  found  in  the  aged  can  be  accounted  for  by 
the  lessened  muscular  activity  and  also  by  lessened  metabolism. 
(The  senile  individual  requires  only  from  75  to  80  per  cent,  of 
the  calories  required  in  maturity.)  The  diminished  surface 
temperature  is  due  to  impaired  surface  circulation  and  changes 
and  not  to  weakened  heat  regulation.  There  are  several  theories 
based  upon  cell  changes.  Ever  since  Schwann  presented  his 
famous  cell  theory,  investigators  have  sought  in  the  cell  the 
solution  of  the  problems  of  life,  of  birth,  of  growth,  decay  and 
death.  The  earliest  of  the  cell  theories  was  presented  by  Can- 
statt.  He  believed  that  the  cause  of  ageing  was  to  be  found  in 
the  cell,  that  the  death  of  the  cell  was  so  much  molecular  death 
of  the  organism  which  was  not  replaced.  Canstatt  did  not  take 
into  consideration  the  repair  of  tissue  through  cell  reproduction 
or  that  in  the  course  of  a  long  life  probably  every  cell  that 
existed  at  birth  had  been  destroyed  and  replaced  repeatedly. 
Minot  gives  as  his  theory  of  ageing  an  increase  in  the  proto- 
plasm and  a  differentiation  of  the  cells. 

The  theory  of  tissue-cell  evolution  which  I  advanced  as  the 
fundamental  cause  of  ageing  is  based  upon  some  facts  and  some 
assumptions.  I  believe  that  there  is  a  progressive  evolution  in 
cell  life;  that  newer  cells  differ  from  their  predecessors;  that  at 
one  stage  of  this  evolution  the  cells  are  most  perfectly  adapted 
to  their  surroundings  and  their  available  nutrition;  that  at  this 
time  the  cells  are  in  the  most  perfect  condition  to  perform  their 
functions;  that  later  cells  are  less  perfectly  adapted  to  the 
conditions  under  which  they  exist;  that  under  these  circum- 
stances fewer  and  more  imperfect  cells  are  formed;  that  finally 
the  cells  are  so  imperfect  and  so  poorly  fitted  for  the  conditions 
under  which  they  exist  that  they  either  do  not  reproduce  or  else 
the  organs  which  they  form  cannot  perform  their  functions. 
Furthermore,  different  kinds  or  classes  of  cells  have  different 
stages  or  periods  of  evolution,  but  tissue  cells  of  the  same  kind 
pass  through  the  same  stages. 

We  know  little  of  the  properties  of  cells.  They  have  the 
power  of  selection  of  nutrition,  of  assimilation,  of  excretion,  of 
growth  and  reproduction,  and  some  have  the  power  of  motion. 
The  why  of  their  activity  is  as  much  a  mystery  as  is  the  source 
of  their  vitality.     May  it  not  be  that  in  the  course  of  the  con- 


44 


PHYSIOLOGICAL   OLD   AGE 


stant  destruction  and  reproduction  of  cell  life  that  is  going  on 
in  the  organism  there  is  also  going  on  a  constant  evolution  in 
cells  ?  It  would  be  analogous  to  what  is  going  on  in  the  more 
complex  forms  of  life.  No  animal  reproduces  its  exact  counter- 
part. There  is  a  difference  in  oysters  coming  from  the  same 
spawn,  in  trees  growing  from  the  seeds  of  the  same  apple. 
Under  the  microscope  a  whole  colony  of  germs  of  the  same 
variety  may  look  alike  yet  under  the  influence  of  a  germicide 
some  will  survive  longer  than  others.  If  they  possess  greater 
vitality  it  is  because  they  possess  qualities  or  properties  making 
them  more  resistant  to  deleterious  influences. 

There  is  a  difference  in  the  properties  of  the  protoplasm  of 
different  kinds,  and  to  the  difference  in  the  proteid  molecules 
is  due  their  diverse  activities.     They   differ  in  their  special 
properties,  the  performance  of  specific  functions,  and  the  general 
cell  properties,  growth,  assimilation,  etc.     They  also  differ  in 
their  tenacity  of  life,  in  their  resistance  to  unfavorable  influences, 
violence,  temperature  changes,  change  of  nutrition,  phagocytes, 
etc.     Slight  differences  may  be  found  in  tissue  cells  of  the  same 
variety  taken  at  the  same  time  from  the  same  tissue,  but  we 
will  never  find  the  great  differences  that  exist  at  different  evolu- 
tionary stages  of  the  same  tissue;  that  is  to  say,  we  will  never 
find  at  the  same  time,  for  example,  degenerate  senile  cells  of  the 
ovary  and  the  early  immature  cells,  though  we  may  find,  during 
the  menopause,  active  cells  and  cells  showing  early  degenerative 
changes.     Of  course,  under  abnormal  disease  conditions  cells  of 
different  stages  of  evolution,  imperfect  cells,  even  cells  of  entirely 
different  character  may  be  found  together.     The  difference  in 
the  length  of  the  period  of  evolution  in  different  cells  can  be 
shown  by  comparing  the  cells  of  the  thymus  gland  with  connect- 
ive-tissue cells.     The  first   indication  of   this  gland  is  a  faint 
line  which  appears  about  the  tenth  week  of  intrauterine  life.     It 
grows  like  all  tissues,  through  cell  growth  and  reproduction, 
the  cells  becoming  larger  and  more  numerous.     The  cells  formed 
about  the  second  or  third  year  of  the  person's  life  are  best 
adapted  to  the  available  nutrition,  to  their  surroundings,  and  to 
the   conditions   under   which   they   exist.     The   cells   and   the 
organ  have  now  reached  their  limit  of  size  and  activity.     No 
satisfactory  explanation  has  yet  been  given  for  limitation  in 
size,  whether  it  be  cells  or  elephants.     To  account  for  the  retro- 
grade evolution  of  the  thymus  we  must  reason  from  analogy. 


CAUSES    OF   AGEING  45 

At  the  time  that  the  cells  are  in  their  most  perfect  condition 
they  receive  an  ample  supply  of  nutrition  from  the  blood  and  as 
there  has  been  a  constant  increase  in  the  rate  of  reproduction 
newer  cells  are  formed  more  rapidly  than  the  waste  of  old  cells. 
But  the  limit  of  available  nutrition  has  been  reached.  The 
amount  of  blood  has  increased,  but  with  the  change  in  diet 
and  the  increase  in  physical  activity  there  has  taken  place  a 
change  in  the  condition  and  composition  of  the  blood,  it  does  not 
contain  enough  of  the  particular  ingredients  necessary  to  supply 
the  thymus  cells.  The  newer  cells  are  consequently  not  in  such 
perfect  condition  as  their  predecessors,  they  are  more  readily 
destroyed  and  they  reproduce  more  imperfect  cells.  The  cells 
are  now  in  the  stage  of  retrogression,  fewer  and  more  imperfect 
cells  are  formed  until  about  the  period  of  puberty  or  a  few  years 
later  when  the  cells  become  extinct.  The  entire  period  of  evolu- 
tion of  the  thymus  gland  cells  is  from  about  fourteen  to  twenty 
years. 

The  evolutionary  changes  in  the  connective-tissue  cells  pro- 
ceed so  slowly  that  it  is  not  until  late  in  life  that  any  marked 
change  in  them  is  observable  and  then  it  is  an  increase  in  rate  of 
growth  and  reproduction.  It  is  impossible  to  follow  up  the 
evolutionary  stages  of  connective  cells  as  the  destruction  of 
their  microcosm,  the  individual,  ends  their  career  while  in  the 
stage  of  active  progressive  evolution.  Let  us  apply  this  theory 
to  the  ovarian  cells.  From  the  beginning  in  intrauterine  life 
there  is  a  slow,  steady  growth  in  number  and  size  of  the  tissue 
cells,  until  at  the  time  of  puberty  they  are  most  perfectly 
adapted  to  their  surroundings,  their  nutrition,  and  the  purposes 
of  the  immature  organ,  but  they  are  not  adapted  to  the  great 
purpose  of  the  ovaries  as  reproductive  organs.  The  period  of 
puberty  is  a  transitional  stage  in  the  evolution  of  ovarian  tissue 
cells,  the  evolutionary  changes  proceeding  rapidly,  the  newer 
cells  having  functional  properties  not  possessed  by  their  predeces- 
sors, the  older  inactive  cells  disappear,  and  by  the  end  of  that 
period  only  new,  active  cells  remain.  For  the  next  thirty  years, 
the  period  of  sexual  activity,  evolutionary  changes  proceed  slowly, 
for  years  they  are  apparently  stationary.  Toward  the  end  of 
the  active  period  the  organ  becomes  less  active  but  is  still  able 
to  perform  its  functions.  The  menopause  is  another  transi- 
tional stage.  The  old  cells  are  still  active  but  the  newer  cells 
have  not  the  same  properties  as  their  predecessors,  the  activity 


46  PHYSIOLOGICAL    OLD   AGE 

of  the  organ  decreases  with  the  gradual  destruction  of  the  old 
active  cells,  and  at  the  close  of  this  period  the  organ  is  composed 
of  cells  having  different  properties  from  the  cells  of  the  active 
period.  These  new  cells  are  not  perfectly  adapted  to  the  con- 
ditions under  which  they  exist  and  they  reproduce  cells  still  less 
fitted  for  those  conditions.  Fewer  and  more  imperfect  cells 
are  formed,  and  the  organ  shrinks.  The  late  cells  are  very  tena- 
cious of  life  and  persist  throughout  the  life  of  the  individual. 

While  cells  of  the  same  variety  pass  through  the  same  evolu- 
tionary stages,  there  may  be  wide  variations  in  the  length  of  time 
required  to  pass  through  each  stage.  Hyperplasia  of  connective 
tissue  may  begin  in  the  thymus  gland  in  the  second  or  third 
year,  when  that  organ  first  begins  to  retrograde,  in  the  ovary 
at  the  menopause,  in  the  brain  at  advanced  old  age.  Puberty 
changes  may  occur  in  one  person  at  eleven  or  earlier,  in  another 
at  sixteen. 

This  theory  is  opposed  to  the  theory  of  the  sudden  conversion 
of  one  variety  of  cell  into  another  variety  of  cell,  as  the  passive 
cell  of  the  hair  cylinder  into  an  active  phagocyte ;  it  is  not,  how- 
ever, opposed  to  the  rapid  conversion  through  intermediate  cells, 
as  the  ovarian  cells  of  the  anteclimacteric  period  into  the  cells 
of  the  postclimacteric  period.  Pathogenic  causes  may  produce 
sudden  and  revolutionary  cell  changes,  but  such  are  not  con- 
sidered in  normal  processes.  This  theory  of  tissue-cell  evolu- 
tion will  explain  the  greater  resistance  to  disease  and  deleterious 
influences  at  one  period  of  life  than  at  another  and  in  one  tissue 
or  organ  than  in  another,  the  formation  of  pathological  proc- 
esses and  their  preference  of  location,  morbid  selection,  per- 
verted activity,  and  the  whole  cycle  of  the  processes  of  life  from 
its  inception  to  its  dissolution. 

The  most  important  factor  in  the  life  of  the  cell  is  its  nutri- 
tion, which  is  derived  from  the  constituents  of  the  blood.  Im- 
pairment of  the  blood,  either  through  the  presence  of  abnormal 
constituents  or  some  alteration  in  quantity  or  quality  of  the  nor- 
mal constituents,  affects  only  those  cells  which  derive  nutri- 
ment from  those  impaired  constituents  or  assimilate  the  toxic 
material.  These  cells  are  weakened,  their  activities  are  im- 
paired, and  they  reproduce  defective  cells.  With  the  improve- 
ment in  nutrition  and  other  conditions  necessary  for  their  ex- 
istence the  cells  improve  and  reproduce  more  perfect  cells. 
This  is  the  process  of  recuperation.     In  senility  the  cells  of  most 


D 
B 


Pancreas  Showing  Increase  of  Fibrous  Tissue. 
Chronic  Interstitial  Pancreatitis.  (From  Coplin's 
"Manual  of  Pathology.")  A,  A.  Areas  of  hemorrhage. 
B,  B  Immature  gland  cells  (bodies  of  Langerhans).  C. 
Gland  acinus.  D,  D,  D,  D,  D.  Fibrous  tissue;  the  areas 
of  rhexis  (A,  A)  are  also  in  the  fibrous  tissue. 


CAUSES    OF   AGEING  47 

tissues  are  retrograding,  and  they  are  not  well  adapted  to  the 
available  nutrition  and  surroundings.  If  there  is  any  perver- 
sion of  this  nutrition,  cell  destruction  proceeds  faster,  reproduc- 
tion is  either  abolished  or  the  new  cells  are  so  defective  that  the 
organs  which  they  form  can  barely  perform  their  functions. 
With  an  improvement  in  the  nutrition  there  may  be  an  improve- 
ment in  the  cells,  but  the  blood  in  old  age  does  not  furnish  the 
best  nutritive  material  to  senile  cells  and  these  cells  reproduce 
cells  still  more  imperfect  than  themselves.  The  altered  meta- 
bolism in  old  age  is  due  to  the  altered  properties  of  senile  cells. 
Late  cartilage  cells  seem  to  have  a  "liking"  for  calcium  salts, 
that  is  to  say,  having  the  power  of  selection  of  nutrition  they 
absorb  such  salts  from  the  blood  more  readily  than  the  cells  at 
an  earlier  period.  Other  senile  cells  show  the  same  tendency. 
Late  cells  seem  to  be  tenacious  of  life  for  they  effectually  resist 
bacteria  and  other  agents  destructive  to  earlier  cells. 

According  to  this  theory  the  vital  resistance  of  the  individual, 
that  is  the  power  of  the  organism  to  resist  certain  pathogenic 
influences,  is  increased  in  old  age.  This  is  diametrically  opposed 
to  the  generally  accepted  view  that  the  vital  resistance  in  the 
aged  is  diminished  in  all  directions,  yet  it  is  well  known  that 
infectious  diseases  are  rare  in  old  age,  that  acute  inflammations 
rarely  occur  and  that  most  diseases  that  are  apt  to  occur  in  the 
aged,  except  those  arising  from  perversions  of  the  normal  senile 
processes,  are  modified  and  less  active  at  that  period  of  life. 
It  is  evident  then  that  either  the  aged  cells  offer  greater  resist- 
ance to  pathogenic  germs  or  that  phagocytosis  is  more  active. 
The  latter  would  account  for  the  milder  attacks  of  infectious 
diseases  the  former  for  their  rarity.  Probably  both  factors 
prevail  in  old  age.  Disease  in  old  age  is  generally  due  to  some 
perversion  of  the  normal  degenerations  due  to  age,  or  to  a  dis- 
turbance in  the  harmonious  relations  between  the  functions, 
caused  by  a  more  rapid  degeneration  in  one  organ  than  in  a  co- 
related  organ.  Where  the  harmonious  relations  are  maintained 
to  the  end,  physiological  death  ensues  without  disease.  In 
such  cases  death  is  due  to  diminution  in  nervous  activity  to  the 
point  of  complete  cessation. 

Senescence  is  not  due  to  any  one  cause.  There  is  undoubt- 
edly a  determining  factor  which  is  the  subject  of  the  various 
theories  that  have  been  advanced,  but  there  are  in  addition 


48  PHYSIOLOGICAL  OLD   AGE 

contributing  factors,  causative  and  resultant,  which  hasten  the 
senile  processes.  With  the  first  breath  that  the  infant  draws 
it  inhales  dust  and  the  foundation  of  pneumokoniosis  is  laid. 
During  the  period  of  lung  growth  the  increase  in  substance  and 
size  of  the  vesicles  prevents  any  impairment  from  the  deposit 
of  dust  in  the  tubes,  finer  bronchioles,  alveoli,  lymph  spaces  and 
connective  tissue.  After  the  lungs  have  ceased  to  grow  the 
deposit  continues,  the  lumen  of  the  finer  tubes  is  diminished, 
the  dust  sets  up  a  pulmonary  fibrosis,  less  air  passes  through 
the  lungs  and  the  blood  is  insufficiently  oxygenated.  Im- 
perfectly aerated  blood  causes  imperfect  nutrition  and  im- 
perfect elimination  of  waste.  In  addition  to  this  there  are 
going  on  in  the  chest  walls  senile  changes  which  compress 
the  lungs,  diminish  their  expansibility  and  thereby  further 
impair  the  respiratory  functions.  The  greater  effort  required 
to  get  sufficient  air  into  the  lungs,  shown  by  the  increased 
number  of  respirations,  puts  a  greater  strain  upon  the  respira- 
tory muscles,  and  the  greater  activity  aroused  increases  the 
waste  which  is  not  fully  repaired  owing  to  the  vitiated  condition 
of  the  blood.  At  the  same  time  the  greater  effort  required  to 
force  sufficient  air  into  the  lungs  and  the  impaired  nutrition  of 
the  vesicular  walls  weaken  the  walls  of  the  latter,  they  become 
thin  and  finally  rupture  producing  senile  emphysema  with 
diminished  aerating  surface,  increased  residual  air  and  lessened 
vital  capacity.  In  the  meanwhile  changes  have  been  going 
on  in  the  heart  and  blood-vessels,  the  blood  supply  is  diminished 
and  later  when  the  heart  becomes  weakened  the  pulmonary  circu- 
lation is  weakened,  still  further  impairing  the  oxygenating  func- 
tion of  the  lung  while  the  impairment  of  the  bronchial  artery  and 
the  vitiated  blood  prevent  the  complete  repair  of  the  lung  tissue, 
which  wastes  more  rapidly  in  its  efforts  to  carry  on  its  functions 
under  difficulties.  In  this  resume  of  the  changes  that  go  in  the 
lungs  in  ageing  we  find  as  the  most  important  contributing 
factor  a  pneumokoniosis  that  began  at  birth.  A  dust-free 
atmosphere  is  theoretically  conceivable  but  practically  impos- 
sible. It  is  true  that  most  of  the  dust  inhaled  is  caught  in  the 
cilia  of  the  bronchi  and  is  expectorated  but  some  does  reach  the 
finer  vessels,  gets  into  the  lymph  channels  and  into  the  substance 
of  the  lung.  This  is  inevitable.  This  pneumokoniosis  is  not 
to  be  considered  in  the  same  light  as  the  vocational  dust  diseases, 


CAUSES   OF   AGEING  4g 

as  the  latter  are  entirely  independent  of  the  senile  changes  and 
cause  a  controllable  irritation  in  the  lung  which  leads  to  lung 
destruction. 

Other  contributing  factors  to  the  senile  changes  cannot  be  even 
theoretically  remedied.  In  the  spleen,  for  example,  there  is 
proliferation  of  connective-tissue  fibers,  some  of  which  compress 
portions  of  spleen  substance  causing  it  to  atrophy,  and  some  of 
the  fibers  crossing  blood-vessels  compress  and  finally  obliterate 
them  thereby  depriving  the  spleen  substance  of  nutrition. 

Disease  is  not  a  causative  nor  even  an  essential  factor  in  physio- 
logical death,  for  disease  is  unnatural  and  in  the  nature  of  an 
accident.  Physiological  death  occurs  without  a  perversion  of 
function  or  structure  which  is  the  essential  element  in  disease. 
Sanitation,  hygiene  and  dietetics  serve  to  prevent  disease  but 
they  have  no  influence  in  prolonging  life  aside  from  the  preven- 
tion of  disease.  The  longevity  of  the  Jews  under  the  most 
unsanitary  conditions  is  proof  of  this  statement.  Other  long- 
lived  nations  such  as  the  Bulgars,  Roumanians  and  Russians 
reach  an  advanced  age  in  utter  disregard  of  sanitary  regulations. 

The  prevalence  of  precocious  senility  in  nations  which  sub- 
ject themselves  to  intense  mental  and  physical  activity  strength- 
ens the  theory  of  tissue-cell  evolution  as  the  determining  cause 
of  ageing.  This  excessive  activity  hastens  the  evolution  of  the 
cells,  by  causing  greater  activity  with  consequent  more  rapid 
destruction  and  reproduction  and  the  earlier  appearance  of 
cells  of  the  later  evolutionary  periods.  I  have  not  touched 
upon  the  factor  of  heredity  as  I  do  not  believe  that  heredity  has 
any  direct  influence  upon  longevity.  Healthy  parents  beget 
healthy  children  and  if  the  children  live  under  the  same  condi- 
tions as  their  parents,  they  have  the  same  chance  to  reach  old 
age.  The  farmer's  son  who  remains  on  the  farm  will  age  more 
slowly  than  his  brother  who  goes  to  the  city. 

The  theory1  of  tissue-cell  evolution  is  in  accord  with  what  we 
know  of  evolution  in  the  higher  and  more  complex  forms  of  life. 
What  the  eon  is  to  the  universe  and  the  geological  period  is  to 
mundane  life  the  years  of  an  evolutionary  stage  are  to  the  cell. 
A  gradual  and  progressive  process,  cell  evolution  is  the  natural 
conclusion  that  has  cosmic  evolution  as  its  major  and  race  evolu- 
tion as  its  minor  premises. 

1  This  theory  of  senescence  was  first  published  in  the  New  York  Medical  Journal, 
Nov.  5,  19 10. 
4 


PART  II 
PATHOLOGICAL  OLD  AGE 


GENERAL  CONSIDERATIONS 

Disease  in  old  age  must  be  looked  upon  not  as  a  pathological 
process  in  an  organ  or  tissue  such  as  we  find  in  maturity  com- 
plicated by  senile  degenerations,  but  as  a  pathological  process 
in  a  normally  degenerating  body,  and  the  perversion  of  function 
is  not  a  perversion  from  the  normal  functions  of  maturity 
but  a  perversion  from  the  functions  that  are  normal  to  the 
degenerating  body.  This  conception  of  disease  in  old  age  will 
lead  to  a  discriminative  valuation  of  the  symptoms  and  signs 
of  disease  and  the  manifestations  of  senility.  The  latter  are 
often  more  pronounced  than  the  symptoms  of  disease  and  unless 
we  can  separate  the  manifestations  of  normal  senile  processes 
from  the  symptoms  of  disease  and  eliminate  the  former  from 
our  diagnosis,  we  will  treat  an  incurable,  progressive,  physio- 
logical degeneration  while  the  disease  is  killing  the  patient. 
Not  infrequently  the  manifestations  of  old  age  simulate  the 
symptoms  of  a  disease  and  the  patient  is  treated  for  a  patho- 
logical condition  which  is  not  present.  Another  frequent  source 
of  error  in  diagnosis  is  due  to  obscure  symptoms  which  may  be 
unnoticed  or  uninterpretable.  This  is  often  the  case  in  senile 
pneumonia,  the  symptoms  of  which  are  at  times  so  mild  as  to 
arouse  no  suspicion  of  the  grave  pathological  condition  present 
until  pulmonary  edema  sets  in.  Another  source  of  error  in 
senile  cases  is  in  the  interpretation  of  symptom  complexes. 
We  often  find  in  maturity  a  number  of  symptoms  which  taken 
collectively  are  diagnostic  of  a  certain  disease.  In  senility 
every  symptom  must  be  traced  to  its  source  before  we  can 
determine  its  relation  to  the  disease  which  we  suspect.  In 
senility  the  severity  of  symptoms  bears  no  relation  to  the 
severity  of  the  disease  nor  does  moderation  of  symptoms  always 
denote  an  improvement  in  the  pathological  conditions.     A  fall 

5i 


^  2  PATHOLOGICAL   OLD   AGE 

in  temperature  may  be  due  to  exhaustion  which  ends  in  death. 
A  rapid  fall  in  blood  pressure  may  be  due  to  sudden  weakening 
of  the  heart,  the  sleep  after  delirium  may  be  a  coma  from  which 
the  patient  will  never  be  roused.     A  rapid  loss  of  weight  may 
be  due  to  waste  of  fat  and  the  wrinkled  skin  after  such  loss 
gives  the  individual  the  appearance  of  age.     A  rise  in  tempera- 
ture is  invariably  due  to  disease  and  the  more  rapid  the  rise 
the  more  serious  the  disease.     If  a  chill  precedes  the  rise  in 
temperature  we  have  a  grave  condition  which  will  probably  end 
fatally.     Temperature  changes  are,  however,  uncertain  indica- 
tions of  the  character  or  severity  of  a  disease,  and  unless  the 
temperature  is  taken  in  the  rectum  it  is  misleading.     Even 
in  health  in  the  aged  there  may  be  a  difference  of  two  degrees 
between  the  rectal  and  axillary  temperature  and  the  same 
difference  can  be  found  in  the  mouth  at  different   times.     It 
is  not  unusual  to  find  a  mouth  temperature  of  97  or  less  in  per- 
fect health.     Elevation  of  temperature  as  the  result  of  disease 
proceeds  less  energetically,  more  slowly,  and  does  not  rise  as  high 
as  in  the  same  disease  in  maturity.     If  the  mouth  temperature  is 
taken  as  is  generally  done  in  adults,  we  are  liable  to  be  several 
degrees  out  of  the  way  and  we  will  get  an  intermittent  or  septic 
temperature  range   due   to  local  causes  not   connected   with 
the  disease.     The  typical  temperature  curves  associated  with 
certain  infectious  diseases  are  rarely  seen  in  old  age.     It  cannot 
be  insisted  upon  too  strongly  that  temperature   in  the  aged 
should  be  always  taken  in  the  rectum  only.     The  pulse  in  old 
age  is  worse  than  useless  as  a  diagnostic  agent,  for  it  will  often 
deceive  us.     As  arteriosclerosis  is  almost  always  present,  the 
artery  is  harder  than  in  maturity  and  we  get  a  hard  pulse  that 
may  simulate  the  pulse  of   serous   inflammations.     We  may 
get  this  pulse  in  aortic  stenosis  in  which  condition  the  pulse  is 
usually  small,  slow  and  weak  and  we  may  get  the  same  pulse  in 
aortic  insufficiency  in  which  disease  in  maturity  we  get  the 
water  hammer  pulse.     There  are  many  conditions  beyond  the 
aortic  orifice  to  modify  the  radial  pulse  and  destroy  its  value  as 
a  diagnostic  agent.     Blood  pressure  in  the  aged  has  not  been 
studied  sufficiently  nor  have  similar  findings  received  similar 
interpretations.     As    we    have    in    almost    every    senile    case 
arteriosclerosis  and  contracted  kidney,  two  causes  for  increased 
pressure,  high  readings  are  physiological  but  no  standard  for 


.r 


h-  \   \^         <$m~  '    Jit      "v  -    ; 


/m^ 


~r 


Group  of  Four  Nerve  Cells  from  the  First  Cervical 
Ganglion  of  a  Man  Dying  of  Old  Age  at  Ninety-two 
Years.  Specimen  preserved  with  osmic  acid.  C,  C,  two 
cells  still  intact,  but  loaded  with  pigment  granules;  c, 
c,  two  cells  which  have  disintegrated.  X500  diams. 
(From  Minot's  "Problems  of  Age,  Growth  and  Death." 
G.  P.  Putnam's  Sons,  New  York  and  London.) 


■*,■.  ^^.   •rk"^  ,.T^  V»„   *.'~.\_^r  *>~       r\ 


Group  of  Five  Nerve  Cells  from  the 
First  Cervical  Ganglion  of  a  Child  at 
Birth.  Specimen  preserved  with  osmic 
acid.  X500  diams.  (From  Minot's 
"Problems  of  Age,  Growth,  and  Death." 
G.  P.  Putnam's  Sons,  New  York  and 
London.) 


GENERAL   CONSIDERATIONS  53 

senile  cases  has  been  established  nor  are  investigators  agreed 
upon  the  meaning  of  deviations  from  the  usual  findings  in  the 
aged.  The  closest  approximation  of  a  standard  of  normal 
blood  pressure  in  the  aged  is  the  age  plus  ioo  in  m.m.  The  face 
gives  us  little  information  in  senile  cases.  There  is  the  expres- 
sionless face  of  senile  dementia  and  of  paralysis  agitans,  the 
latter  disease  being  readily  distinguished  from  the  former  by 
the  tremor  and  brighter  mentality.  There  may  be  jaundice 
indicating  biliary  obstruction  or  cancer;  in  apoplexy  the  face 
is  puffed  and  congested ;  in  chronic  nephritis  puffy  and  muddy 
or  pasty  looking;  it  is  flushed  in  hyperemia  and  fevers,  pale 
in  anemia,  sallow  in  various  cachexias;  but  these  facial  indica- 
tions have  only  a  secondary  value.  Almost  every  one  who  has 
reached  advanced  age  has  led  an  out-door  life,  his  skin  is 
tawny  and  weather-beaten  and  does  not  readily  show  these 
changes.  The  contracted  pupils  which,  are  normal  to  old  age 
may  mislead  us,  the  dribbling  of  saliva  may  suggest  salivation, 
occasionally  one  sees  the  stare  which,  associated  with  contracted 
pupils,  is  found  in  mania.  This  will  be  found  in  the  aged  indi- 
vidual who  has  presbyopia  and  does  not  wear  his  glasses  when 
he  makes  an  effort  to  see  a  speaker  close  by.  Ordinarily  the 
aged  patient  is  apathetic  or  if  he  realizes  the  seriousness  of  his 
condition  he  is  anxious  or  depressed.  In  most  diseases  having 
a  fatal  outcome,  the  mind  becomes  dull  and  as  the  end 
approaches  the  patient  becomes  unconscious.  Pain  is  an 
uncertain  symptom  in  old  age,  as  it  is  frequently  referred  to 
some  organ  or  tissue  not  diseased  and  it  is  often  absent  or  slight 
in  diseases  in  which  pain  is  usually  a  prominent  symptom. 
The  absence  of  this  symptom  in  pneumonia,  gastritis,  peritonitis, 
etc.,  may  lead  to  a  wrong  diagnosis  or  to  the  neglect  of  the 
disease  by  the  patient  himself  until  death  ensues.  Gangrene 
seldom  gives  pain  and  it  may  be  neglected  until  extensive 
necrosis  has  occurred.  This  absence  of  pain  in  senile  diseases 
is  usually  associated  with  weakened  mentality  and  it  is  probable 
that  the  mental  condition  is  responsible  for  the  lack  of  apprecia- 
tion of  painful  sensations,  as  well  as  the  condition  of  the  nerve 
terminals.  There  may  be  on  the  other  hand  hyperesthesia  and 
paresthesia,  especially  itching,  so  severe  as  to  require  medical 
attention,  yet  no  pathological  lesion  can  be  found.  The 
altered  reflexes  in  old  age  frequently  make  a  correct  diagnosis 


54  PATHOLOGICAL    OLD    AGE 

difficult  and  if  the  disease  is  one  in  which  the  state  of  the  re- 
flexes is  diagnostic  or  confirmatory  of  a  diagnosis,  it  is  almost 
impossible  to  avoid  error.  Investigators  have  found  the  foot 
reflex  absent  in  over  80  per  cent,  of  cases  between  sixty-five 
and  ninety-three  years  of  age,  yet  the  knee  reflex  was  increased 
in  32  per  cent,  and  absent  in  but  20  per  cent.  These  findings 
show  the  unreliability  of  the  state  of  the  tendon  reflexes  as  a 
diagnostic  aid  in  old  age.  If  there  are  two  conditions  present 
which  ordinarily  give  different  reflexes  we  must  omit  the 
tendon  reflex  entirely  in  determining  our  diagnosis.  A  fre- 
quent source  of  error  in  diagnosis  in  senile  cases  is  the  changed 
position  into  which  organs  are  forced  through  anatomical 
changes  in  other  structures.  The  flabby  abdominal  muscles 
and  weakened  diaphragm  permit  the  liver  to  sink  until  in  excep- 
tional cases  the  upper  border  can  be  felt  below  the  ribs.  In 
these  cases  the  organ  appears  to  be  much  larger  than  when  the 
outlines  can  be  determined  only  by  percussion.  The  stomach  also 
sinks  when  the  abdominal  walls  are  flaccid  and  the  intestines 
are  empty,  but  when  the  bowels  are  filled  with  flatus  the  stomach 
may  be  raised  or  pushed  to  one  side.  Owing  to  the  rigid  chest 
walls  and  wasted  intercostals  the  apex  beat  may  be  quite  pro- 
nounced even  in  the  case  where  the  heart  is  weak  as  in  cardiac 
dilatation.  The  weakened  diaphragm  allows  the  heart  to  sink 
until  the  apex  is  3  inches  below  the  nipple  and  further  to  the 
left  than  in  maturity,  yet  a  dilated  stomach  or  intestines  dis- 
tended with  gas  can  raise  the  diaphragm  and  push  the  heart 
further  up  and  to  the  left.  In  determining  the  meaning  of  an 
abnormal  position  of  the  heart,  the  condition  of  the  stomach 
and  intestines  must  be  taken  into  account.  Owing  to  the 
rigidity  of  the  chest  walls  inspection  gives  us  little  information 
of  pathological  conditions  within  the  walls,  while  the  up  and 
down  respiratory  motion  is  apt  to  mislead  us.  In  senile  pneu- 
monia the  apex  is  generally  affected,  but  the  lungs  in  old  age  are 
atrophied  and  we  must  look  for  the  altered  percussion  note  in  the 
infraclavicular  space.  Slight  bulgings  between  the  ribs  are 
generally  due  to  pleuritic  effusion,  but  owing  to  the  rigid  chest 
walls  the  diagnosis  must  be  made  by  percussion  and  ausculta- 
tion in  different  positions.  The  interpretation  of  heart  murmurs 
occasionally  gives  some  trouble  if  two  or  more  valves  are  affected, 
especially  if  in  addition  there  is  an  aortic  bruit.     Combined  val- 


GENERAL   CONSIDERATIONS  rr 

vular  defects  are  the  rule  in  old  age  and  when  the  rhythm  is 
irregular  it  is  often  impossible  to  make  a  diagnosis  from  the  mur- 
murs alone.  It  is  sometimes  necessary  to  feel  the  carotid  pulsa- 
tion or  the  apex  beat  to  determine  whether  a  murmur  is  systolic  or 
diastolic.  In  aortic  stenosis  the  murmur  may  be  loud  enough  to 
mask  the  less  audible  systolic  murmurs  of  mitral  regurgitation 
and  dilatation  of  the  arch  of  the  aorta,  while  in  aortic  and  mitral 
regurgitation  and  in  aortic  obstruction  with  dilated  aorta — the 
most  frequent  combination  of  valvular  lesions — systolic  and 
diastolic  murmurs  are  heard  all  over  the  chest  and  the  diagnosis 
must  be  made  by  accompanying  symptoms  and  signs.  Not- 
withstanding the  vastly  inferior  methods  of  diagnosis  of  abdom- 
inal disorders  as  compared  with  the  methods  applicable  to  tho- 
racic diseases,  errors  in  diagnosis  are  less  liable  to  happen  in  the 
former  class  of  cases.  The  principal  sources  of  error  in  abdominal 
disease  are  absence  of  pain  in  usually  painful  diseases  especially 
inflammations,  abnormal  position  of  organs  or  tissues,  symp- 
toms apparently  connected  with  other  organs  than  the  one  dis- 
eased, symptoms  referable  to  a  diseased  organ  but  differing 
from  the  ordinary  symptoms  of  the  suspected  disease,  and  mani- 
festations of  senility  simulating  a  disease.  Some  of  these  sources 
of  error  have  already  been  discussed.  An  example  of  symptoms 
referable  to  other  than  the  diseased  organ  is  seen  in  the  asthma 
and  vertigo  frequently  associated  with  acute  gastritis,  and  some- 
times more  pronounced  than  the  gastric  symptoms.  The  ab- 
sence of  prominent  symptoms  of  a  disease  occurs  more  frequently 
than  the  presence  of  exceptional  symptoms.  Postmortem  ex- 
aminations frequently  reveal  lesions  that  gave  no  symptoms  dur- 
ing life,  even  of  such  diseases  which  give  pronounced  symptoms 
and  signs  when  occurring  in  maturity.  Gastric  ulcers  have  been 
found  after  death  in  cases  where  there  had  been  no  pain,  vomit- 
ing or  hyperacidity  during  life.  Vomiting  is,  however,  frequently 
absent  in  old  age  in  diseases  in  which  it  is  a  prominent  symptom 
in  maturity.  Diarrhea  is  comparatively  infrequent  in  the  aged 
and  in  almost  every  case  can  be  traced  to  some  fault  in  the  food. 
When  it  occurs  in  connection  with  other  diseases  it  has  little  or 
no  diagnostic  value.  Constipation,  when  the  only  symptom,  is 
generally  due  to  diminished  peristalsis  and  has  no  diagnostic 
value,  except  as  an  expression  of  the  physiological  senile  changes 
in  the  intestines.     When  associated  with  other  symptoms  not 


5  6  PATHOLOGICAL   OLD   AGE 

due  to  the  constipation,  its  significance  is  uncertain.  (This 
and  diarrhea  will  be  discussed  fully  in  the  article  on  senile 
changes  in  the  intestines.)  In  many  cases  of  abdominal  disease 
the  etiology  and  history  of  the  case  will  give  more  information 
than  the  symptoms  and  signs.  On  the  whole  the  diagnosis  of 
this  class  of  diseases  is  not  difficult  if  we  remember  the  senile 
changes  and  eliminate  their  normal  manifestations.  Far  more 
difficult  is  the  diagnosis  of  diseases  of  the  nervous  system  owing 
to  the  diverse  character  of  the  senile  changes  in  the  organs,  and 
their  manifestations.  It  is  often  a  question  of  personal  opinion 
whether  the  functional  changes  are  normal  or  abnormal,  physio- 
logical or  pathological.  The  difficulty  is  increased  through  the 
resemblance  of  some  of  the  altered  functions  to  the  impaired  func- 
tions of  certain  disease  conditions.  The  senile  gait  and  senile 
tremor  may  resemble  the  gait  and  tremor  of  paralysis  agitans,  the 
senile  dementia  of  cerebral  atrophy  is  like  the  dementia  of  cere- 
bral softening  and  the  dementia  following  melancholia;  the 
changed  reflexes  in  old  age  suggest  various  nervous  diseases. 
The  altered  reflexes  and  weakened  power  of  coordination  that  we 
frequently  find  are  symptoms  of  well-defined  diseases,  yet 
postmortem  examinations  may  fail  to  show  the  lesions  asso- 
ciated with  such  diseases.  Notwithstanding  these  difficulties  the 
practical  elimination  in  old  age  of  tabes  dorsalis  and  diseases  in- 
volving increased  functional  activity  simplifies  the  diagnosis. 
Of  the  general  neuroses  senile  tremor  and  paralysis  agitans  are 
most  frequent,  and  neurasthenia  is  sometimes  seen.  Vertigo 
occurs  quite  frequently  in  old  age  and  is  almost  always  due  to 
cerebral  arteriosclerosis.  Of  the  psychoses,  melancholia  and 
hypochondria  are  frequent,  occasionally  there  is  amentia  or 
paranoia,  rarely  mania.  There  is  little  difficulty  in  their  diagno- 
sis. Dementia  is  the  usual  outcome  of  the  psychoses  of  old  age 
and  the  termination  of  senile  atrophy  and  cerebral  softening.  A 
temporary  dementia  may  follow  apoplexy.  Arteriosclerosis  of 
the  cerebral  vessels  is  the  most  frequent  cause  of  mental  impair- 
ment and  the  same  disease  in  the  vessels  of  the  cord  is  responsible 
for  many  of  the  diseases  of  the  cord  and  spinal  nerves.  Men- 
ingeal diseases  are  rare  in  old  age  and  when  they  do  occur  at  that 
time  of  life  they  are  almost  always  secondary.  Other  cerebral 
diseases,  such  as  anemia,  hyperemia,  hemorrhage,  embolus  and 
thrombus  and  the  diseases  resulting  from  them,  are  generally 


The  "worm-eaten"  brain.     A  rare  and  extreme  form  of  senile 
degeneration.     (Williams  Medical  Record,  Nov.  23,  191 2.) 


GENERAL   CONSIDERATIONS  cy 

traceable  to  atheroma  and  present  no  serious  difficulty  in  their 
diagnosis  as  they  do  not  differ  from  the  same  diseases  occurring 
in  maturity.     Some  writers  describe  a  senile  paraplegia  as  a 
distinctive  disease,  but  there  is  no  unanimity  in  their  description 
of  the  disease  and  they  agree  only  on  one  symptom,  a  progres- 
sive weakness  of  the  lower  limbs.     As  this  may  be  due  to  various 
conditions  of  the  brain  and  cord  and  to  the  physiological  changes 
caused  by  ageing — perhaps  to  the  simple  waste  of  muscle — the 
term  senile  paraplegia  will  be  used  to  denote  the  one  symptom  and 
not  a  well-defined  disease.     The  most  frequent  spinal  disease 
in  old  age  is  myelitis,  although  there  are  frequently  symptoms 
pointing  to  other  degenerative  diseases,  principally  to  degenera- 
tion of  the  lateral  and  posterior  fibers.     The  principal  disorders 
of  the  peripheral  nerves  are  neuritis,  neuralgia  and  disorders  of 
sensation  and  of  the  special  senses.     In  some  cases  it  is  difficult 
to  determine  whether  the  impairment  of  the  special  sense  is  due 
to  central  or  to  peripheral  disease,  especially  as  no  change  of  a  de- 
generative character  has  been  demonstrated  in  the  taste  bulbs 
or  in  the  middle  ear  (except  waste  of  the  drum),  nor  in  the  sen- 
sory terminals  of  touch.     In  making  a  diagnosis  in  a  senile  case, 
we  must  determine  to  what  extent  the  symptoms  are  modified 
by  the  mental  state  of  the  individual.     Weakness  and  the  fear 
of  falling  may  produce  a  gait  similar  to  the  gait  of  spastic  paral- 
ysis.    Mental  dulness  may  produce  lessened  appreciation  of  pain, 
and  on  the  other  hand  fear  of  pain  may  cause  excessive  sensitive- 
ness, hyperesthesia  and  even  paresthesia.     Whenever  we  must 
depend  upon  the  patient's  intelligence  for  diagnostic  information, 
we  must  endeavor  to  secure  corroboration  of  the  patient's  state- 
ments.    Incidental  complications,  i.e.,  those  due  to  the  senile 
disease,   and    accidental  complications,    those   not   due   to    or 
connected  with  the  primary  disease,  occur  frequently  in  the 
course  of  senile  diseases.     In  maturity  such  secondary  diseases 
are  often  preventable  and  generally  curable.     In  senility  they 
are  rarely  either  avoidable  or  curable,  as  they  are  caused  by  the 
efforts  of  co-related  organs  to  maintain  harmonious  relations 
with  the  diseased  organs,  such  efforts  increasing  or  perverting  the 
functions  of  the  secondary  organs  and  hastening  their  own  degen- 
eration.    In  the  pneumonia  of  maturity,  for  example,  the  action 
of  the  heart  is  increased  in  force  and  rapidity,  thereby  increasing 
pulmonary  circulation  in  the  unaffected  part  of  the  lungs,  while 


58  PATHOLOGICAL    OLD    AGE 

the  increased  respiration  serves  to  oxygenate  the  increased 
amount  of  blood  sent  by  the  heart,  thereby  maintaining  the 
circulation  of  properly  oxygenated  blood  throughout  the  system. 
If  the  heart  is  in  good  condition  it  can  keep  up  this  rapid  pace 
for  days  without  impairment.  In  pneumonia  in  old  age  the  in- 
creased activity  of  the  heart,  which  is  already  working  to  the 
limit  of  its  capacity,  rapidly  exhausts  the  organ.  Death  from 
disease  in  old  age  is  rarely  due  to  the  primary  disease  but  to  the 
inevitable  secondary  involvement  of  vital  organs  or  to  general 
physical  exhaustion.  In  making  a  prognosis  we  must  consider 
not  only  the  disease  itself,  but  the  capacity  of  the  co-related 
organs  and  to  what  extent  they  can  stand  further  strain  upon 
them.  In  the  treatment  of  diseases  the  first  as  well  as  the  ulti- 
mate aim  of  the  physician  should  be  to  prevent  the  immediate 
cause  of  death.  If  there  is  a  persisting  cause  of  the  disease  which 
can  be  reached  and  removed,  that  should  receive  attention  be- 
fore any  treatment  itself  is  instituted.  In  most  cases,  however, 
the  cause  even  if  persisting  cannot  be  removed  and  we  must 
treat  the  results.  In  the  great  majority  of  cases  the  immediate 
cause  of  death,  i.e.,  the  determining  factor  which  causes  death,  is 
not  the  disease  but  either  general  exhaustion  or  exhaustion  with 
paralysis  of  the  heart.  There  are  other  immediate  causes  of 
death,  such  as  paralysis  of  the  brain,  shock,  asphyxia,  etc.,  but 
general  asthenia  and  heart  failure  are  the  most  prevalent  and 
the  danger  that  one  or  the  other  may  set  in  is  present  in  almost 
every  senile  disease.  The  prevention  of  these  two  dangers  must 
therefore  engage  the  physician's  attention  from  the  beginning 
of  every  disease  in  old  age.  Even  in  diseases  like  apoplexy, 
cerebral  embolism  and  various  toxemias  which  paralyze  the 
brain,  cases  occur  which  are  prolonged,  and  secondary  con- 
ditions arise  which  may  end  in  exhaustion  or  heart  failure. 
These  dangers  should  be  guarded  against  as  soon  as  the  secondary 
conditions  appear. 

A  serious  difficulty  in  the  treatment  of  diseases  of  old  age 
is  the  uncertainty  of  the  action  of  drugs  upon  the  senile  organism. 
We  know  little  of  the  physiological  action  of  drugs  uptm  normally 
degenerating  tissue  and  we  know  virtually  nothing  of  the  thera- 
peutic action  of  drugs  upon  diseased  degenerating  tissue.  Drugs 
which  are  almost  specifics  in  certain  diseases  in  maturity  may  be 
ineffectual   in   similar   conditions   in   senility.     Assimilation  is 


GENERAL    CONSIDERATIONS  t-Q 

changed  and  drug  activity  is  slower  and  prolonged  and  we  con- 
sequently get  the  effects  that  smaller  doses  produce.  Secondary 
effects  are  sometimes  more  pronounced  than  the  primary  ones 
and  thus  we  may  get  unexpected  results.  In  some  cases  the 
etiological  factors  influence  the  action  of  drugs.  In  arterio- 
sclerosis due  to  alcoholism,  lead,  syphilis,  gout,  nephritis  and  other 
diseases,  the  cure  of  the  disease  is  accompanied  by  an  improve- 
ment in  the  condition  of  the  vessels.  In  such  cases  the  iodides 
will  cure  arteriosclerosis.  If,  however,  the  disease  of  the 
arteries  is  not  secondary  but  is  merely  a  simple  senile  degenera- 
tion, the  iodides  have  no  action  other  than  the  physiological 
effect  of  the  drug  upon  the  organism.  Drugs  that  have  a  bene- 
ficial effect  upon  the  kidney  of  interstitial  nephritis  have  no  effect 
upon  the  senile  contracted  kidney,  although  the  two  resemble 
each  other  and  the  senile  kidney  may  present  an  albuminous 
urine.  This  may  be  used  as  an  argument  in  favor  of  the  state- 
ment that  the  senile  degenerations  are  essentially  different  from 
the  diseases  which  present  the  same  morphological  features  in 
maturity,  that  for  example  the  arteriosclerosis  following  syphilis 
is  a  different  disease  from  the  arteriosclerosis  which  appears 
as  the  physiological  senile  change.  In  some  cases  where  the 
incidental  effects  of  drugs  are  more  pronounced  than  the  primary 
effect,  the  secondary  effect  may  destroy  the  primary  effect  or 
produce  other  deleterious  results.  This  is  well  seen  in  using 
digitalis  as  a  heart  tonic  in  cases  where  there  is  arteriosclerosis. 
The  drug  acts  primarily  as  a  heart  tonic,  increasing  the  force  of 
the  contractions.  The  secondary  effect  is  vasoconstriction 
whereby  the  lumen  of  the  vessels  is  diminished.  Fortunately 
digitalis  in  powder  or  tincture  acts  slowly,  but  if  the  active  prin- 
ciple is  used  hypodermically  the  action  is  more  rapid,  and  athero- 
matous cerebral  vessels  are  contracted  and  at  the  same  time 
they  are  subjected  to  the  increased  pressure  exerted  by  the  heart. 
Being  unable  to  stand  the  strain  they  rupture  and  apoplexy  is 
the  result.  Some  drugs  which  are  readily  absorbed  in  maturity 
are  absorbed  so  slowly  in  senility  as  to  be  virtually  inert.  This 
is  the  case  with  cinchona  and  other  tannin-bearing  drugs. 
The  same  sometimes  happens  with  gelatine,  and  gelatine-coated 
pills  and  capsules  may  pass  through  the  stomach  unchanged. 
Owing  to  the  generally  slower  assimilation  and  the  constipa- 
tion of  old  age  cumulative  effects  are  more  frequent  at  that 


60  PATHOLOGICAL   OLD   AGE 

period  of  life.  This  is  especially  true  of  opium  and  bella- 
donna which  lessen  peristalsis  in  the  already  weakened  in- 
testines. In  combining  drugs  to  overcome  undesirable  by- 
effects  the  corrective  may  itself  have  undesirable  secondary 
effects.  This  is  seen  in  the  popular  aloin,  strychnine  and 
belladonna  pill  in  which  the  belladonna  is  given  to  overcome 
the  griping  effect  of  the  aloin,  by  allaying  the  peristalsis,  to 
produce  which  we  give  the  aloin.  Incidentally  the  belladonna 
lessens  the  intestinal  secretions  making  it  still  more  undesir- 
able in  senile  constipation.  The  usual  combination  of  mor- 
phine and  atropia  is  irrational  and  dangerous  in  old  age  as 
it  gives  a  false  sense  of  security  in  cases  where  morphine  action 
is  desired.  Morphine  beside  its  primary  analgesic  effect  para- 
lyzes the  respiratory  centers  and  to  prevent  this  the  atropia 
is  added.  But  morphine  acts  more  rapidly  than  atropia  and 
in  the  aged  where  these  centers  are  already  weakened,  the 
morphine  may  kill  before  the  atropia  has  begun  to  act. 
Herein  lies  the  great  danger  in  giving  morphine  to  the  aged. 
If  atropia  is  given  a  few  minutes  before  we  give  the  morphine 
or  if  morphine  be  given  per  os  and  a  hypodermic  of  atropia 
is  given  at  the  same  time  morphine  can  be  given  in  as  large  a 
dose  as  in  maturity. 

The  old  dictum  that  children  and  the  aged  cannot  stand  large 
doses  does  not  hold  good  when  applied  to  the  latter  except  in 
a  few  drugs.  Many  drugs  can  and  must  be  given  in  larger  doses 
in  old  age  to  be  effective.  In  senile  constipation,  for  example, 
we  give  intestinal  peristaltic  stimulants,  beginning  with  the 
smallest  effective  dose.  As  in  time  the  waste  and  atony  of  the 
muscular  fibers  of  the  intestines  proceed  in  the  process  of  involu- 
tion, and  the  peristalsis  diminishes,  we  must  gradually  give  larger 
doses  of  the  stimulant  until  many  times  the  original  dose  is 
required  to  have  any  effect.  Not  infrequently  an  initial  dose 
of  1/8  grain  of  aloin  must  be  gradually  increased  to  2  or  3  grains. 
This  is  not  due  to  habituation  only,  for  if  we  change  the  drug 
the  new  drug  must  be  given  in  correspondingly  large  doses. 
The  system  does  become  habituated  to  a  drug,  especially  in 
old  age,  but  this  can  be  readily  overcome  by  an  occasional  change. 

As  weakened  functional  activity  and  secondary  effects  re- 
sulting therefrom  are  the  most  prevalent  of  the  senile  ailments, 
tonics  and  stimulants  are  the  drugs  mostly  used  in  senile  cases, 


GENERAL   CONSIDERATIONS  6 1 

and  as  functional  weakness  increases  increased  doses  of  the  drugs 
must  be  given.  Sedatives  and  hypnotics  are  rarely  required 
in  old  age  although  they  are  apparently  often  indicated.  When 
they  are  employed  they  should  be  given  in  the  smallest  effective 
dose,  reduced  after  the  initial  dose  and  stopped  entirely  as  soon 
as  the  desired  effect  is  obtained.  This  does  not  apply  to  cases 
where  the  full  effect  is  to  be  derived  from  a  single  dose,  as  when 
giving  an  analgesic.  In  such  cases  a  single  full  dose,  to  be 
given  with  proper  precautions  for  avoiding  the  incidental  effects 
of  the  drug,  is  better  than  repeated  small  doses.  It  is  often  im- 
possible to  decide  whether  the  pain  from  which  the  patient  com- 
plains is  real  or  whether  the  fear  of  pain  creates  the  impression 
of  pain  or  produces  an  oversensitiveness  that  exaggerates  simple 
tenderness  into  pain.  If  the  disease  is  usually  painful  there  will 
probably  be  real  pain  and  morphine  is  indicated.  If  it  be  merely 
oversensitiveness  a  placebo,  preferably  one  containing  aloes, 
quinine  or  some  other  disagreeable  drug,  should  be  given. 
In  many  cases  the  patient  will  rather  stand  the  pain  than  take 
the  drug  and  he  will  often  declare  that  the  pain  is  bearable  or 
has  entirely  disappeared  under  such  treatment.  The  aged 
frequently  complain  that  they  cannot  sleep  at  night  and  the 
physician  is  tempted  to  give  a  hypnotic.  On  close  questioning 
in  these  cases  it  will  be  found  that  while  the  aged  patient  can- 
not sleep  for  more  than  a  few  hours  at  night  he  takes  frequent 
naps  during  the  day  and  the  total  amount  of  his  sleep  in  naps, 
dozes  and  sound  sleep  may  be  from  ten  to  fifteen  hours  out  of 
the  twenty-four.  These  cases  are  hard  to  handle  as  the  patient 
does  not  realize  that  his  naps  sometimes  last  for  hours,  that  the 
little  doze  after  reading  the  papers,  etc.  (really  due  to  brain 
fag),  is  sleep,  and  that  he  sleeps  so  much  in  short  stretches  during 
the  day  that  the  system  does  not  require  more  than  a  few  hours 
sleep  at  night.  Where  there  is  real  insomnia  it  is  better  to  try 
hot  baths,  hot  drinks,  suggestion  and  other  non-medicinal 
measures  before  resorting  to  hypnotics.  Chloral  is  useless  in 
small  doses  and  dangerous  in  large  doses  on  account  of  its 
depressing  effect  upon  the  heart.  Veronal  is  perhaps  the  safest 
hypnotic  in  old  age  and  if  the  insomnia  is  due  to  mental  agitation 
— a  frequent  cause  in  the  aged — veronal  and  monobromated 
camphor  is  a  safe  and  effective  combination.  The  bromides 
are  occasionally  required  to  allay  nervous  excitability.     The 


62  PATHOLOGICAL   OLD   AGE 

sodium  salt  is  preferable  to  the  potassium  salt  as  the  former 
contains  10  per  cent,  more  of  the  bromine  element  and  much  less 
of  the  alkali  than  the  latter  and  is  besides  not  as  irritating  to 
the  stomach.  The  chronic  nervous  diseases  of  maturity  seldom 
reach  old  age  and  rarely  originate  in  old  age.  Paralysis  agitans, 
the  one  which  occurs  most  frequently  in  the  aged,  is  not  influ- 
enced by  the  bromides,  while  senile  tremor  is  aggravated  by 
this  class  of  drugs. 

^  Drug  action  is  influenced  by  the  mode  of  administration. 
Drugs  should  never  be  given  in  the  form  of  gelatine-coated  pills 
or  capsules.  Salts  given  in  solution  are  absorbed  quickly  but 
if  given  in  powder  form,  their  action  depends  upon  their  solu- 
bility. Hours  and  sometimes  days  pass  before  the  action  of 
insoluble  salts  like  calomel  and  bismuth  is  recognized.  Drugs 
like  arsenic,  phosphorus,  etc.,  which  may  produce  local  irritation 
in  the  stomach,  should  always  be  given  in  solution  well  diluted. 
Where  there  is  danger  of  cumulative  effects  care  should  be  taken 
to  secure  free  evacuation  of  the  bowels  by  active  cathartics. 
The  gastric  and  intestinal  ferments  have  little  effect  in  old  age 
but  predigested  food  is  rapidly  absorbed.  Drugs  used  for  local 
absorption  by  inunction  must  be  combined  with  an  animal  base, 
either  lanoline,  lard  or  sweet  butter.  Vegetable  fats  and  oils 
are  absorbed  with  difficulty — and  mineral  bases  are  not  absorbed 
at  all  by  the  dry  skin  in  old  age.  The  same  applies  to  liniments. 
They  may  produce  local  irritation  through  friction  but  an  animal 
oil  or  alcohol  is  necessary  if  we  want  to  secure  the  absorption  of 
the  drug. 

Hydrotherapy  has  a  wide  range  of  application  in  senile  cases. 
The  aged  object  to  the  inconvenience  connected  with  entering 
a  bath  especially  if  their  joints  are  stiff.  They  cannot  stand  the 
shock  of  a  cold  bath  and  even  an  ice  bag  may  give  a  dangerous 
shock.  Neither  can  they  stand  the  depletion  produced  by  exces- 
sive diaphoresis.  Tepid  and  warm  baths  and  packs  act  well  in 
every  case  where  a  temporary  sedative  action  is  desired,  and  a 
tepid  bath  followed  by  friction  acts  as  a  stimulant.  A  warm 
bath  followed  by  inunction  will  sometimes  relieve  the  stiffness 
of  joints  due  to  the  senile  changes  and  occasionally  the  stiffness 
found  in  various  forms  of  arthritis. 

Electrotherapy  has  not  been  sufficiently  studied  in  the  aged 
to  make  a  positive  statement  as  to  its  value.     Where  there  is  a 


GENERAL   CONSIDERATIONS 


63 


partial  electrical  reaction  of  degeneration  the  faradic  current 
will  produce  a  temporary  stimulation  of  nerves  and  muscles,  but 
if  the  reaction  of  degeneration  is  complete  the  faradic  current 
has  no  effect.  Mechanotherapy  has  some  application  in  senile 
cases  as  massage,  friction  and  passive  exercise.  It  should  be 
remembered  that  excessive  activity  in  muscles  hastens  their 
degeneration  and  the  increased  activity  of  the  heart  in  forced 
active  exercise  may  cause  loss  of  compensation  and  rapid  ex- 
haustion. The  condition  of  the  heart  must  be  the  guide  in  the 
application  of  mechanotherapeutics  in  the  aged. 

Serotherapy  has  not  been  sufficiently  employed  in  the  aged 
to  determine  its  value.  The  diphtheria  antitoxin  has  a  more 
profound  systemic  action  on  the  aged  than  in  childhood  and  the 
danger  from  anaphylaxis  is  apparently  greater.  This  last  was 
probably  the  cause  of  the  unfortunate  results  obtained  from  the 
use  of  Brown-Sequard's  testicular  extract. 

Treatment  at  mineral  springs  is  much  more  in  vogue  in  Europe 
than  in  America.  Mineral  waters  generally  are  contraindicated 
in  the  aged  and  there  are  but  few  diseases  in  which  the  benefits 
derived  will  compensate  for  their  disadvantages.  The  only 
diseases  in  the  aged  which  show  greater  improvement  from  a 
course  of  treatment  at  springs  than  from  home  measures  are 
cholelithiasis,  diabetes  and  gout.  It  is  probable  that  the  strict 
regimen  enforced  at  the  European  springs  contributes  as  much 
to  the  result  as  the  waters  themselves,  because  the  same  regimen 
at  home  with  the  bottled  waters  does  not  produce  the  same 
results.  The  psychic  influence  is  absent  at  home  and  even  at 
American  springs  where  the  patient  can  keep  in  touch  with  his 
home  and  business  and  thus  keep  up  the  cares  and  worries  which 
frequently  contribute  to  the  disease. 

In  the  treatment  of  diseases  the  author  mentions  only  such 
drugs  and  measures  as  he  has  found  to  be  of  service,  omitting 
the  host  of  drugs  and  measures  recommended  by  other 
writers. 

The  senile  changes  bring  about  vicious  circles  which  increase 
in  number  and  size  until  every  organ  and  tissue  and  every  func- 
tion is  involved.  In  atheroma  the  weakened  elastic  fibers  di- 
minish the  elasticity  of  the  vessels  and  the  heart  must  send  blood 
with  greater  force  through  these  vessels  to  maintain  the  circula- 
tion.    This  puts  the  fibers  still  further  on  the  stretch,  weakening 


64  PATHOLOGICAL   OLD   AGE 

them  more  and  more.  The  weakened  muscular  fibers  of  the 
colon  permit  dilatation  of  that  part  of  the  intestines  and  feces 
collect  in  the  pouch  thus  formed,  distending  the  pouch,  stretch- 
ing the  remaining  fibers  and  further  weakening  them.  Similar 
vicious  circles  are  formed  in  the  stomach  and  bladder.  The 
dilated  stomach  permits  the  accumulation  of  food  which  fur- 
ther weakens  its  walls,  the  dilatation  is  increased  through  this 
accumulation  of  food  and  gas  and  this  in  turn  impairs  the  di- 
gestive power  of  the  organ. 

The  dilated  atonic  bladder  holds  urine  through  its  inability 
to  void  it;  this  increases  the  dilatation  and  permits  more  urine 
to  collect  in  the  larger  saccules  thus  formed,  the  sacs  stretching 
the  muscular  fibers  and  weakening  them  more  and  more.  Owing 
to  the  atrophy  of  the  lung  and  waste  of  the  interalveolar  septa, 
the  aerating  surface  of  the  lungs  is  diminished  and  the  blood  is 
improperly  oxygenated.  The  capacity  of  the  blood  to  carry 
nutrition  to  the  organs  is  thereby  impaired  and  this  includes  the 
lungs  where  the  increasing  atrophy  further  diminishes  the  aerat- 
ing surface.  The  most  pernicious  of  the  vicious  circles  is  formed 
in  the  heart  after  the  limit  of  compensatory  hypertrophy  is 
reached.  The  heart  is  now  no  longer  able  to  overcome  the 
impairment  caused  by  diminished  expansibility  of  the  arteries, 
dilated  veins  and  weakened  valves,  its  tonicity  is  lessened  and 
it  sends  blood  with  less  force  through  the  system.  The  circula- 
tion is  slowed  and  weakened  and  the  elimination  of  waste  and  the 
supply  of  nutrition  is  slower  and  thus  the  nutrition  of  the  heart 
itself  is  impaired.  This  further  weakens  the  organ  and  still 
further  weakens  the  circulation.  Retardation  of  the  pulmonary 
circulation  causes  an  accumulation  of  blood  in  the  right  heart, 
producing  dilatation  and  under  the  combined  influences  of 
stretching  of  the  cardiac  walls,  insufficient  nutrition  and  exces- 
sive work  to  empty  overfilled  cavities,  the  heart  rapidly  degene- 
rates, it  becomes  exhausted  or  paralyzed.  It  requires  careful 
discrimination  to  separate  the  manifestations  of  physiological 
senile  changes  from  the  symptoms  of  disease.  The  treatment  of 
the  diseases  in  the  aged  is  still  mainly  empirical ;  every  case 
requires  individual  attention  and  routine  measures  based  upon 
the  same  conditions  as  found  in  maturity  are  certain  to  lead  to 
disaster.  We  must  look  upon  senility  apart  from  maturity  and 
its  diseases,  as  sui  generis  senile  diseases. 


CLASSIFICATION   OF  DISEASES  IN  OLD   AGE  65 

CLASSIFICATION  OF  DISEASES  IN  OLD  AGE 

There  is  probably  no  other  branch  of  science  in  which  nomencla- 
ture and  classification  are  as  imperfect  as  in  medicine.  Some  med- 
ical terms  indicate  the  pathological  condition,  as  chronic  paren- 
chymatous nephritis,  or  acute  follicular  tonsillitis;  some  point 
to  the  etiology,  as  sunstroke,  hay  fever,  etc. ;  some  are  purely 
symptomatic,  as  neuralgia,  tachycardia,  hematemesis;  some 
are  generic  and  are  applied  to  several  pathological  conditions 
which  resemble  each  other  in  one  or  more  symptoms  or  in  the 
location  of  symptoms,  as  rheumatism,  pneumonia;  some  bear 
the  name  of  the  physician  who  first  described  the  symptoms  or 
investigated  the  disease,  as  Bright's  Disease,  Addison's  Disease, 
Bell's  Paralysis;  while  some  terms  do  not  refer  to  either  the 
etiology,  pathology  or  symptoms  present. 

In  our  nosology  there  is  neither  order  nor  system.  One 
author  follows  an  alphabetical  arrangement  beginning  with 
abortion  and  ending  with  yellow  fever.  Older  writers  generally 
classify  diseases  according  to  the  organs  or  system  of  organs  in 
which  they  occur,  as  diseases  of  the  circulatory  system,  digestive 
system,  etc.  Recent  authors  use  an  etiological  and  regional 
classification  separating  infectious  and  parasitic  diseases  from 
the  others  and  dividing  the  latter  according  to  the  system  to 
which  the  affected  organ  belongs.  A  more  recent  classification 
is  devised  according  to  the  initial  cause  and  divides  diseases  into 
physical,  chemical,  animate,  mental  and  nutritional  diseases. 
A  revolutionary  revision  of  our  nomenclature  is  necessary 
before  we  can  place  upon  a  scientific  basis  medical  terms  and  the 
classification  of  diseases,  and  until  this  is  accomplished  every 
classification  must  be  imperfect. 

The  basis  of  the  classification  employed  in  this  book  is  the 
relation  of  the  pathological  condition  to  the  senile  organism.  It 
divides  the  diseases  found  in  the  aged  into  five  groups  as  follows : 

(1)  Primary  senile  diseases,  i.e.,  diseases  in  which  there  is 
an  increase,  decrease  or  perversion  of  the  ordinary  senile  anatom- 
ical or  physiological  changes. 

(2)  Secondary  senile  diseases,  i.e.,  diseases  which  result 
from  the  senile  changes. 

(3)  Modified  diseases  of  old  age,  i.e.,  diseases  which,  when 
occurring  in  old  age  are  modified  by  the  senile  conditions,  or 
present  features  not  found  in  maturity. 

s 


66  PATHOLOGICAL    OLD    AGE 

(4)  Preferential  diseases  of  old  age,  i.e.,  diseases  which  occur 
most  frequently  in  advanced  life. 

(5)  Diseases  uninfluenced  by  age  or  are  rare  in  old  age. 
Strictly  speaking,  every  disease  is  influenced  by  age  but  the 
diseases  of  the  fifth  group  are  those  which  do  not  differ  mate- 
rially in  etiology,  pathology  or  symptoms  from  the  same  dis- 
eases in  maturity. 

The  first  group  includes  diseases  which  present  abnormalities 
in  the  normal  process  of  involution.  As  we  have,  however,  no 
standard  of  the  normal  senile  conditions  and  no  means  of  estab- 
lishing a  norm,  it  will  be  necessary  to  include  the  ordinary  senile 
degenerations  under  this  heading  as  nearly  all  produce  discom- 
fort or  give  rise  to  secondary  pathological  conditions.  We  must 
remember  that  even  slight  changes  may  cause  profound  func- 
tional manifestations  and,  on  the  other  hand,  there  may  be  exten- 
sive anatomical  changes  in  organs  and  tissues,  without  disturb- 
ing their  harmonious  relations  with  allied  organs  and  tissues  or 
producing  symptoms  of  disease.  The  true  senile  diseases  may  be 
primary,  i.e.,  the  cells  degenerate  through  some  property  in 
the  cells  themselves,  such  as  has  been  suggested  in  the  theory 
of  tissue-cell  evolution,  or  they  may  be  secondary  to  arterio- 
sclerosis and  then  due  to  malnutrition.  These  are  all  included 
under  the  first  group.  Changes  identical  with  senile  changes 
may  be  found  as  the  result  of  other  etiological  factors.  Arterio- 
sclerosis may  be  due  to  syphilis  and  other  toxemias,  to  excessive 
food  during  prolonged  inactivity,  to  cardiac  disease,  etc.  It  is 
possible  that  future  research  may  disclose  some  intrinsic  differ- 
ence between  the  tissues  degenerating  through  the  normal  proc- 
ess of  involution  and  those  degenerating  from  disease.  That 
there  is  some  difference  is  evident  from  the  functional  differ- 
ences and  from  a  difference  in  the  action  of  drugs. 

Diseases  of  the  first  group  are  organic  or  functional,  the 
functional  diseases  presenting  functional  perversions  for  which 
no  histological  change  can  be  found.  Included  in  the  functional 
diseases  are  senile  tremor,  senile  impotence,  senile  pruritus, 
senile  cachexia,  and  true  senile  dementia  which  is  a  symptom 
of  cerebral  atrophy  and  degeneration. 

Many  diseases  belong  to  two  or  more  groups.  These  will 
be  described  in  the  group  most  closely  allied  to  the  senile  state, 
as  chronic  endocarditis  which  may  be  primary,  secondary  or 


SENILE    CACHEXIA 


67 


modified  and  which  occurs  most  frequently  after  middle  age, 
and  is  placed  in  the  first  group  under  degenerations  of  the  heart. 
Senile  emphysema  belongs  to  the  first  group  while  ordinary 
emphysema  which  is  rare  in  the  aged  and  does  not  differ  from 
the  same  disease  in  earlier  life,  is  omitted.  Senile  non-infect- 
ious pneumonia  belongs  to  the  second  group,  while  infectious 
pneumonia,  whether  localized  or  diffused,  belongs  to  the  fifth 
group.  In  order  to  preserve  continuity  of  description  it  was 
found  advisable  in  some  cases  to  describe  a  disease  belong- 
ing to  one  group  with  a  disease  of  another  group.  Doubtful 
etiology  may  have  caused  improper  grouping.  Arrhythmia 
which  is  probably  due  to  some  disturbance  of  the  vagus  and  would 
therefore  belong  to  diseases  of  the  nerves,  is  placed  in  the  second 
group  under  cardiac  neuroses  and  angina  pectoris  is  placed  in 
the  same  class,  although  it  is  often  a  symptom  of  coronary  arterio- 
sclerosis which  belongs  under  primary  senile  diseases.  Senile 
tremor  is  placed  in  the  first  group  on  the  assumption  that  it  is 
a  symptom  of  general  debility  of  the  aged  and  due  to  cerebro- 
spinal degeneration. 

Where  the  etiology  and  pathology  of  a  functional  disorder 
is  unknown  or  uncertain  it  is  placed  with  diseases  of  a  like  char- 
acter which  can  be  classified.  Other  diseases  with  obscure  eti- 
ology and  pathology  are  placed  in  the  fourth  group  if  they  occur 
frequently  in  the  aged,  or  else  in  the  fifth  group  if  they  do  not 
fit  under  any  other  head. 

This  classification  must  be  revised  as  our  knowledge  of  the 
pathogenesis  of  diseases,  like  gout,  diabetes,  cancer,  pernicious 
anemia,  etc.,  increases. 

Parasitic  diseases,  rare  tropical  diseases  and  diseases  which 
in  the  aged  do  not  differ  from  the  diseases  of  maturity  have 
generally  been  omitted. 

PRIMARY  SENILE  DISEASES 
SENILE  CACHEXIA 

Senile  Debility 

This  term  is  employed  to  cover  the  vitiated  condition  of  the 
senile  organism.  It  includes  the  lowered  functional  activity  and 
capacity  and  the  obvious  manifestations  of  ageing,  which  form 
the  tout  ensemble  of  senile  debility. 


68  PATHOLOGICAL   OLD    AGE 

Pathology.  The  Blood. — While  neither  chemical  nor  micro- 
scopic examination  of  the  blood  of  the  aged  has  revealed  any  ab- 
normal constituent  or  any  marked  disproportion  of  normal  con- 
stituents as  compared  with  the  blood  of  younger  individuals, 
there  is  undoubtedly  some  change  in  the  character  of  the  blood 
of  the  aged.  It  has  a  high  percentage  of  hemoglobin  in  spite  of 
its  readiness  to  part  with  it  to  form  pigment  deposits  in  the  areas 
of  degeneration  and  of  passive  hyperemia.  It  has  a  tendency 
to  hold  the  products  of  defective  metabolism  thereby  giving 
rise  to  the  diseases  of  metabolism.  Its  nutritive  value  is  lowered, 
as  its  ability  to  carry  nutrition  to  the  organs  and  waste  from  the 
organs  is  diminished.  In  twelve  out  of  thirteen  examinations 
reported  by  Grawitz,  the  leucocytes  numbered  between  4000  and 
8000,  and  the  red  cells  between  4,470,000  and  5,300,000,  the 
hemoglobin  percentage  was  between  90  and  no  and  specific 
gravity  between  105 1  and  1060.  Notwithstanding  the  profound 
anatomical  change  in  the  senile  spleen  and  in  the  character  of  the 
bone  marrow,  the  number  of  cells  are  not  reduced.  The  high 
specific  gravity  is  due  to  a  diminution  of  the  watery  element 
and  the  blood  of  the  aged  is  consequently  more  viscid  than  in 
maturity.  This  favors  coagulability  with  slowed  current  and  pro- 
duction of  thrombi  and  emboli.  With  the  same  proportion  of 
water  as  in  earlier  life  the  other  constituents  would  be  proportion- 
ately reduced  and  there  would  be  an  anemia  with  deficient  cell 
elements  and  salts.  The  proportion  of  chloride  of  sodium  is 
less  in  the  blood  of  the  aged  and  there  is  an  increase  in  lime  but 
these  variations  are  slight.  (Other  anatomical  and  physio- 
logical changes  that  contribute  to  the  general  condition  are  de- 
scribed under  anatomical  and  physiological  changes  in  old  age.) 
The  sallowness  of  the  aged  is  not  due  to  the  condition  of  the  blood 
but  to  deficient  surface  circulation  and  consequent  changes  in 
the  integument.  In  many  cases  of  senile  debility  the  anatom- 
ical and  physiological  changes  are  slight  and  the  condition  can 
be  traced  to  psychic  causes. 

Etiology. — The  underlying  causes  of  senile  cachexia  are  the 
underlying  causes  of  ageing.  The  obvious  manifestations  are 
due  mostly  to  the  anatomical  and  physiological  changes.  There 
are,  however,  some  etiological  factors  that  deserve  special  con- 
sideration. There  is  a  remarkable  similarity  between  the  ca- 
chexia of  old  age  and  the  cachexia  of  unsanitary  life.  In  the 
latter  there  is  generally  insufficient  food,  in   the  former  there 


SENILE    CACHEXIA 


69 


is  impaired  assimilation  of  food  producing  the  same  effect. 
The  aged  do  not  get  sufficient  air  into  their  lungs  to  completely 
oxygenate  the  blood  owing  to  anatomical  changes  in  the  lungs 
and  chest  wall.  Those  living  unsanitary  lives  do  not  get  suffi- 
cient pure  air  into  their  lungs  owing  to  unwholesome  surroundings. 
The  effect  of  insufficient  sunshine  upon  the  latter  has  its  counter- 
part in  the  effect  of  sunshine  upon  the  weather-beaten  skin. 
In  both  cases  there  are  sallowness,  weakened  vital  functions, 
lessened  resistance  to  disease,  slow  and  incomplete  recuperation, 
yet  in  both  the  blood  count  is  normal  and  the  cells  show  no 
abnormalities.  It  is  probable  that  sunlight  itself  or  its  absence 
is  a  factor  in  ageing,  as  those  who  are  deprived  of  sunlight, 
like  miners,  persons  working  in  cellars  or  who  work  at  night,  are 
usually  sallow  or  pale  and  age  rapidly,  while  the  withdrawal 
from  night  work  has  a  rejuvenating  effect. 

The  general  physical  weakness  that  accompanies  ageing  is 
due  to  the  anatomical  and  histological  changes  in  the  joints, 
the  waste  and  atony  of  muscle  and  lessened  innervation.  In 
the  muscles  the  contractile  power  is  diminished,  and  the  re- 
sponses to  stimuli  and  to  the  will  are  slower  and  less  active, 
fatigue  sets  in  more  rapidly,  is  more  profound,  and  recovery 
takes  longer.  The  joints  become  stiffened;  coordination  is 
more  difficult  and  it  often  requires  a  conscious  effort  or  impulse 
to  bring  about  coordinate  movements  that  have  usually  been 
performed  unconsciously. 

In  addition  to  these  senile  changes  involved  in  the  production 
of  senile  debility,  there  is  always  a  psychic  factor  which  may 
be  more  pronounced  than  the  senile  changes.  This  psychic 
factor  may  be  causative  or  resultant,  aiding  in  the  production 
of  senile  debility  or  arising  from  a  recognition  of  such  debility, 
but  in  either  case  it  tends  to  exaggerate  the  objective  and 
subjective  manifestations  of  this  condition.  True  physical 
debility  caused  by  the  anatomical  changes  in  the  bones,  joints, 
muscles  and  motor  nerves,  is  progressive,  the  extent  of  the  weak- 
ness depending  upon  the  extent  of  the  senile  changes,  and  tem- 
porary forced  stimulation  is  followed  by  more  rapid  degenera- 
tion. In  many  cases,  however,  the  debility  is  apparently 
greater  than  the  anatomical  changes  would  warrant,  while  there 
is  a  profound  mental  depression  without  marked  mental  impair- 
ment.    In  these  cases  the  debility  bears  a  relation  to  the  mental 


70  PATHOLOGICAL   OLD    AGE 

attitude  and  little  or  no  relation  to  the  physical  condition  of  the 
individual.  In  every  case  of  senile  debility  physical  and  psychic 
factors  are  involved,  the  latter  playing  but  an  insignificant  part 
in  some  cases,  while  in  others  it  may  be  the  main  etiological 
factor. 

Symptoms. — Obvious  manifestations  of  senile  debility  are 
described  in  the  chapter  on  the  Senile  State.  Aside  from  the 
changes  in  the  skin  and  hair,  and  waste  of  tissue,  the  most 
pronounced  manifestation  is  the  posture  and  gait  of  the  aged. 
Owing  to  anatomical  changes  in  the  spinal  column  and  chest 
walls  there  is  an  exaggerated  dorsal  curvature  and  flattening  or 
retraction  of  the  anterior  surface  of  the  chest,  the  weakened 
muscles  of  the  back  and  neck  allow  the  body  to  sink  and  the  head 
to  fall  forward;  the  shoulders  droop,  the  arms  hang,  and  the 
lower  limbs  are  bent  at  the  hips  and  knees  to  maintain  equilibrium. 
This  characteristic  senile  stoop  does  not  appear  in  any  disease 
but  it  may  be  simulated  by  the  slouch  of  psychic  pseudo-senile 
debility.  It  is  necessary  to  distinguish  between  the  senile 
stoop  and  the  senile  slouch — the  former  due  to  the  anatomical 
changes  and  coming  on  slowly  and  late ;  the  latter  due  to  psychic 
causes  and  coming  on  rapidly  and  early. 

The  most  natural  position  of  an  individual  is  the  one  involv- 
ing the  least  physical  effort,  namely,  one  permitting  complete 
relaxation  of  the  muscles.  The  ordinary  position  with  head  up, 
shoulders  thrown  back,  chest  out,  the  individual  standing  as 
erect  as  possible,  is  the  result  of  effort  which  long  continued 
finally  becomes  a  habit.  The  child  is  taught  to  sit  straight  and 
to  stand  straight  yet  there  is  always  the  tendency  to  relapse  into 
slouching  position.  This  tendency  overcomes  the  habit  during 
sleep,  under  depressing  emotion,  and  in  some  persons  in  whom  the 
effort  to  maintain  the  erect  posture  has  not  become  a  fixed  habit. 
The  habit  is  later  maintained  by  a  sense  of  pride  in  one's  appear- 
ance, the  erect  bearing  being  more  pleasing  to  the  eye,  the  indi- 
vidual being  thereby  better  able  to  secure  public  recognition  and 
approval.  When  an  aged  person  begins  to  feel  the  infirmities 
that  come  with  advancing  years,  the  labored  breathing  upon 
slight  physical  effort,  the  fatigue  that  sets  in  rapidly,  the  stiffen- 
ing of  the  joints  and  the  fact  that  the  usual  labors  become 
more  difficult — he  then  realizes  that  he  is  on  the  downward 
journey  of  life.     To  some  this  comes  as  a  shock,  to  others  as 


SENILE    CACHEXIA 


71 


the  realization  of  a  long  anticipated  misfortune.  It  produces  a 
mental  depression,  which  is  sometimes  so  profound  that  ambi- 
tion is  lost,  there  is  no  longer  any  pride  in  appearance  and 
the  mind  is  centered  upon  life  itself.  Some  fear  that  they  have 
not  provided  sufficiently  for  their  declining  years,  others  that 
they  may  become  a  burden  upon  those  who  might  wish  to  be 
relieved  of  this  burden.  In  some  cases  the  loss  of  sexual  virility 
will  produce  this  mental  depression.  Whatever  the  cause  may 
be,  the  loss  of  pride  in  the  carriage  or  bearing  of  the  individual 
brings  about  the  natural  tendency  to  slouch  and  the  individual 
assumes  this  position.  Worry  will  hasten  the  appearance  of 
age  and  in  a  short  time  the  ageing  individual  presents  the  general 
appearance  of  old  age  and  senile  debility.  We  frequently  find 
that  an  improvement  in  the  mental  condition  is  followed  by 
restoration  of  physical  vigor  and  it  is  generally  noted  that 
decrepit  persons  lose  the  appearance  of  decrepitude  and  gain 
in  physical  strength  upon  their  admission  to  a  home  or  asylum 
where  they  are  free  from  worry.  In  almost  every  case  where 
senile  debility  occurs  early  and  proceeds  rapidly  the  psychic 
factor  is  the  main  cause. 

The  impairment  of  the  special  senses,  mental  impairment, 
intensified  emotions,  especially  fear,  minor  physical  defects,  as 
broken-down  arches,  hypersensitiveness,  etc.,  must  all  be  in- 
cluded in  the  conception  of  senile  debility  as  they  all  increase  the 
helplessness  of  the  individual.  These  are  wilfully  exaggerated 
in  pseudo-senile  debility  but  appear  none  the  less  real  to  the 
patient.  It  is  difficult  to  draw  a  sharp  line  between  this  condi- 
tion and  senile  neurasthenia.  The  neurasthenic  generally  main- 
tains his  pride  in  appearance  and  overcomes  the  tendency  to 
slouch  or  be  may  lapse  into  a  slouch  from  which  he  can  be 
roused  with  little  effort,  while  it  often  requires  all  the  skill  and 
tact  of  the  physician  to  rouse  the  other  even  temporarily. 

Senile  debility  is  sometimes  complicated  by  senile  tremor 
and  senile  dementia.  The  tremor  is  probably  due  to  degenera- 
tion of  the  spinal  cord  and  will  be  treated  under  that  head. 
It  does  not  appear  in  debility  of  psychic  origin  except  when  ac- 
quired through  imitation.  A  slow,  progressive  senile  debility 
and  dementia  occur  normally  after  the  senile  climacteric  and  may 
then  simulate  general  paresis.  The  latter  disease  occurs  earlier 
in  life,  there  is  usually  a  specific  history,  a  history  of  convulsions, 


72  PATHOLOGICAL   OLD   AGE 

delusions  of  grandeur,  rapid  mental  and  physical  decay  with 
periods  of  temporary  improvement.  These  features  are  absent 
in  senile  debility  with  dementia.  There  are  several  pathological 
conditions  marked  by  tissue  waste  and  debility  without  other  pro- 
nounced symptoms  of  disease.  Schoenlein's  senile  marasmus — 
an  atrophy  of  the  stomach  and  intestines — may  simulate  true 
senile  debility — or  may  occur  with  the  latter.  In  Schoenlein's 
disease  there  is  an  excessive  amount  of  feces  and  lientery, 
while  the  characteristic  stoop  is  absent  unless  senile  debility 
is  present. 

Carcinoma,  tuberculosis,  marasmus,  etc.,  produce  waste  of 
tissue  and  debility,  but  in  these  cases  the  rapid  emaciation 
attracts  the  physician's  attention  and  he  looks  for  a  well-defined 
disease.  Tuberculosis  especially  is  liable  to  be  mistaken  for 
senile  debility  and  its  true  nature  may  be  overlooked  until  the 
disease  is  far  advanced.  Rapid  emaciation  with  debility  and 
without  other  marked  symptoms  or  with  an  afternoon  rise  in 
temperature  points  to  tuberculosis. 

Treatment. — The  treatment  of  senile  debility  includes  med- 
ical, psychic  and  hygienic  measures. 

The  medicinal  measures  have  for  their  object,  (i)  the  func- 
tional stimulation  of  muscles  and  nerves,  (2)  the  relief  of  the 
stiffness  of  the  joints,  (3)  improvement  of  the  mental  attitude, 

(4)  relief  of   minor   ailments   associated    with   senile   debility, 

(5)  general  tonic  treatment. 

Phosphorus,  strychnine,  and  arsenic  meet  the  first,  third, 
and  fifth  of  these  indications.  Arsenic  increases  bodily  vigor, 
stimulates  the  appetite,  favors  constructive  metabolism  and 
improves  the  general  physical  condition  of  the  individual.  It 
is  the  most  valuable  tonic  fcr  the  aged,  but  it  is  a  treacherous 
drug,  the  limit  of  tolerance  being  sometimes  reached  in  two  or 
three  months  and  at  other  times  two  or  three  doses  given  in 
twelve-hour  intervals  to  the  same  person  will  produce  a  cumula- 
tive toxic  effect  of  the  combined  dose.  Strychnine  is  a  powerful 
nerve  stimulant,  having,  however,  the  serious  drawback  that 
it  increases  heart  action  as  well.  If  there  is  cardiac  hypertrophy 
— the  usual  condition  of  the  heart  before  decompensation — it  is 
contraindicated.  When  there  is  no  contraindication  to  its  use  it 
can  be  combined  with  arsenic  as  strychnine  arsenate  in  doses  of 
1/100  grain.     The  dose  of  the  arsenic  in  this  salt  is  small  and 


SENILE    CACHEXIA 


73 


there  is  no  danger  of  rapid  toxic  effect.  If  there  is  an  objection  to 
strychnine,  the  arsenic  should  be  given  alone  or  with  phosphorus, 
in  doses  of  1/40-1/20  grain  of  the  arsenic  trioxide  or  six  minims 
of  Fowler's  solution  twice  daily.  As  soon  as  cramps  or  pain  in 
the  stomach,  a  distaste  for  food,  or  swelling  under  the  eyelids 
appear,  the  drug  must  be  stopped.  Phosphorus  is  a  mental 
stimulant,  nerve  tonic  and  aphrodisiac  which  has  no  cumulative 
effect,  and  no  reaction;  its  action  is  prolonged  and  it  can  be 
discontinued  without  detrimental  effect.  It  increases  mental 
activity  and  produces  a  sense  of  well  being,  rousing  frequently  a 
desire  for  increased  physical  exercise.  It  can  be  given  in  doses 
of  1/100  grain  of  the  ordinary  phosphorus,  or  2  grains  of  the 
amorphous,  non-toxic  red  phosphorus.  Lecithin,  notwithstand- 
ing its  organic  phosphorus  content,  does  not  produce  the  same 
effect  as  the  inorganic  drug. 

Phosphorus  should  be  given  until  there  is  a  noticeable  im- 
provement in  the  patient's  mental  attitude.  Whenever  mental 
depression  appears  again  its  use  must  be  resumed  in  an  increased 
dose. 

Opium  and  its  preparations  are  active  cerebral  stimulants 
in  small  doses,  but  the  effect  soon  wears  off  and  there  is  danger 
of  habituation.  They  are  not  mental  restoratives,  for  the  reason- 
ing power  acts  vicariously;  ideas  are  more  florid,  the  imagina- 
tion is  stimulated,  but  memory  is  not  improved,  as  neither  the 
receptive  nor  retentive  power  is  strengthened.  Cocaine  is  a 
cerebral  stimulant  and  produces  a  sense  of  well  being  but  it  is 
always  dangerous  in  the  aged  especially  so  in  the  arteriosclerotic. 
Coffee  or  caffeine  can  be  used  as  a  general  stimulant  without 
danger. 

The  treatment  for  stiffening  of  the  joints  is  given  in  the 
chapter  on  Arthrosclerosis  Senilis  and  the  treatment  of  the 
minor  ailments  is  given  under  their  various  headings. 

Psychic  measures  are  most  important  in  pseudo-senile 
debility  and  are  of  some  service  in  the  true  senile  debility.  The 
old  soldier  hobbling  along  on  Decoration  Day  makes  a  firmer 
step,  walks  erect  and  becomes  spry  and  lively  as  he  passes  the 
reviewing  stand.  Flattery  has  a  more  permanent  rejuvenating 
effect,  especially  flattery  from  a  young  person  of  the  opposite 
sex.  Association  with  younger  persons  on  the  plane  of  com- 
panionship and  especially  marriage  with  a  younger  person  will 


t 


74  PATHOLOGICAL   OLD   AGE 

do  more  to  dispel  the  feeling  of  mental  and  physical  debility 
than  any  medical  measures.  The  ancient  Romeo  who  goes 
courting  becomes  young  in  feelings  and  forces  himself  to  both 
actions  and  looks  to  correspond  with  his  mental  attitude. 
Where  the  psychic  factor  causing  the  general  weakness  was 
worry,  relief  from  this  worry  will  relieve  the  debility.  This  ac- 
counts for  the  improvement  of  aged  persons  immediately  upon 
a  change  of  environment — interesting  sights  that  do  not  confuse 
or  fatigue,  old  familiar,  lively  airs,  the  pursuit  of  a  harmless 
hobby;  anything  that  will  tend  to  divert  the  mind  from  the 
body  and  from  death  will  have  a  beneficial  effect  upon  them. 
The  benefit  derived  from  the  freedom  from  worry  upon  en- 
tering a  home  for  the  aged,  is  soon  dissipated  when  the  aged 
person  finds  his  associates  complaining  of  their  petty  ills  and 
when  he  sees  these  associates  dying.  The  aged  person  should 
have  a  pleasant  young  companion,  preferably  of  the  opposite 
sex,  constantly  around  him. 

The  hygienic  treatment  will  be  given  in  the  chapter  on 
Hygiene. 

SENILE   ARTERIOSCLEROSIS 

Arteriosclerosis  is  the  most  frequent  and  in  its  consequences 
the  most  important  of  all  senile  degenerations.  Faulty  nomen- 
clature and  a  failure  to  differentiate  between  different  forms  of 
arterial  degeneration  are  responsible  for  the  many  misconcep- 
tions concerning  this  condition  which  in  its  milder  form  is 
natural  and  normal  in  old  age. 

The  terms  arteriosclerosis,  atherosclerosis,  atheroma,  arterio- 
capillary  fibrosis,  arterial  sclerosis,  atheromatosis,  arteritis  de- 
formans, endarteritis  nodosa,  endarteritis  deformans,  periar- 
teritis, have  all  been  used  interchangeably  or  to  designate  one 
form  or  another  of  arterial  degeneration,  thereby  creating  con- 
fusion. Bishop  introduced  the  term  cardiovascular  disease  to 
cover  a  clinical  syndrome  including  disease  of  the  heart  and  of 
the  blood-vessels,  arteriosclerosis  and  the  co-related  conditions 
of  autointoxication,  neurasthenia,  kidney  degeneration,  etc. 

The  term  is  unfortunate  since  it  includes  many  conditions 
which  differ  in  association,  pathology  and  symptoms,  hence 
it   does  not  represent  a  definite  entity. 


SENILE    ARTERIOSCLEROSIS  75 

The  term  senile  arteriosclerosis  is  applied  to  a  form  of  arterial 
degeneration  which  is  part  of  the  process  of  involution ,  not  due 
to  antecedent  disease,  is  progressive  and  incurable.  A  pure 
senile  arterial  degeneration  uninfluenced  by  any  other  factor  than 
the  underlying  cause  of  ageing  is  hardly  conceivable.  It  will 
therefore  be  necessary  to  describe  other  forms  in  order  to  under- 
stand the  ordinary  degeneration  found  in  the  aged.  Arterio- 
sclerosis is  divided,  (i)  as  to  extent,  into  circumscribed  and  diffuse 
or  general,  the  former  involving  one  or  more  circumscribed  areas, 
the  latter  involving  to  some  extent  most  or  all  of  the  arteries 
of  the  body;  (2)  as  to  location,  aortic,  cerebral,  coronary,  radial, 
etc.,  depending  upon  the  vessel  involved;  (3)  as  to  etiology, 
physiological  as  occurs  in  the  normal  process  of  involution, 
presenile  when  the  process  is  normal  but  hastened,  and  patho- 
logical when  due  to  disease ;  (4)  as  to  pathology,  inflammatory 
when  beginning  as  an  endarteritis,  mechanical  when  beginning 
by  loss  of  tonicity  of  the  muscular  coat,  and  nutritional  when  due 
to  interference  with  the  nutrition  of  the  vessel  through  inflam- 
mation or  blocking  of  the  vasa  vasorum;  (5)  as  to  prognosis, 
temporary  and  permanent,  the  former  curable,  the  latter 
incurable;  (6)  primary  or  secondary,  the  latter  when  following 
and  due  to  another  disease. 

Etiology. — The  basic  cause  of  physiological  or  senile  arterio- 
sclerosis is  the  basic  cause  or  causes  of  ageing.  Any  of  the 
fundamental  causes  of  senile  involution,  whether  ascribing  the 
initial  changes  to  the  blood,  to  the  blood-vessels  or  to  the  cells 
can  be  made  to  fit  the  etiology  of  senile  arteriosclerosis. 

The  prevalent  view  of  German  physicians  favors  Thoma's 
histo-mechanical  theory  and  loss  of  tonicity  of  the  muscle 
fibers.  In  France  and  America  Metchnikoff's  autointoxication 
theory  with  endothelial  irritation  and  inflammation  is  favored. 
A  more  recent  theory  ascribes  the  basic  cause  to  hyperactivity 
of  the  adrenals  whereby  a  contraction  of  the  arterioles  is  pro- 
duced and  consequently  the  vasa  vasorum  receive  a  diminished 
supply  of  blood  and  the  larger  vessels  are  insufficiently  nourished. 
While  the  senile  changes  in  the  blood-vessels  can  be  explained 
by  the  cell-evolution  theory,  it  has  not  been  verified  and  it  is 
presented  here  as  a  possible  cause,  acting  alone  or  in  combina- 
tion with  other  causes.  The  main  objection  to  Thoma's  theory 
is  the  fact  that  in  most  cases  endarteritis  or  degeneration  due  to 


76  PATHOLOGICAL   OLD    AGE 

insufficient  nutrition  occurs  before  the  appearance  of  muscle 
atonicity,  as  evidenced  by  vascular  dilatation.  The  objections 
to  the  theory  of  autointoxication  as  the  basic  cause  in  normal 
degeneration  are  that  feeding  animals  with  sterile  food  causes 
death,  that  meat  is  supposed  to  be  the  principal  source  of 
alimentary  autointoxication  yet  vegetarians  have  arteriosclerosis 
and  the  amount  of  meat  consumed  bears  no  relation  to  the  extent 
of  the  degeneration,  and  that  autointoxication  goes  on  almost 
from  birth.  It  is  undoubtedly  a  very  potent  contributing  factor 
but  it  cannot  be  accepted  as  the  determining  cause.  A  deter- 
mining or  basic  cause  must  produce  like  results  under  like 
conditions  and  such  results  must  always  be  traceable  to  such 
cause.  Applying  this  test  to  the  autointoxication  theory  we 
find  that  the  absorption  of  the  products  of  intestinal  decomposi- 
tion does  not  always  produce  arteriosclerosis  nor  can  we  trace 
every  case  of  arteriosclerosis  to  this  cause. 

The  discovery  of  Josue  that  the  .  injection  of  adrenalin 
in  rabbits  produces  arterial  degeneration  is  the  basis  of  the  theory 
of  adrenal  hyperactivity.  The  adrenal  secretion  has  a  selec- 
tive property  upon  the  arterioles,  contracting  them  thereby  di- 
minishing the  blood  supply  to  the  vasa  vasorum  which  arise  from 
the  arterioles.  This  would  seem  to  indicate  that  the  disease 
arising  from  adrenal  hyperactivity  has  a  causal  relation  with 
increased  blood  pressure.  Adler  has  shown  that  the  disease  pro- 
duced experimentally  is  not  identical  with  arteriosclerosis  in 
the  human  subject,  that  other  substances  can  produce  the  same 
lesions,  and  that  the  injection  of  adrenalin  does  not  always  pro- 
duce arterial  degeneration.  L.  Braun,  using  adrenalin  and 
amyl  nitrite,  produced  the  lesion  in  the  aorta  without  increased 
blood  pressure  and  a  like  result  was  obtained  by  the  use  of  other 
substances  which  have  little  or  no  effect  upon  the  blood.  It  is 
evident  that  the  action  of  adrenal  secretion  when  in  excess  is 
not  due  to  its  blood-raising  property  but  to  its  toxic  effect. 
It  has  been  shown  that  nicotine  will  stimulate  the  adrenals  and 
this  has  been  advanced  to  explain  the  prevalence  of  the  disease 
in  tobacco  smokers.  It  is,  however,  a  question  whether  the 
effect  of  tobacco  is  due  to  the  action  of  the  poison  upon  the  adre- 
nals, or  upon  the  vasomotor  centers  or  to  the  irritant  action  of 
the  nicotine  upon  the  vessels  themselves.  The  divergence  of 
opinion  based  upon  contrary  results  of  similar  experiments  can 


SENILE   ARTERIOSCLEROSIS 


77 


be  explained  only  by  the  failure  to  recognize  different  local  and 
general  conditions.  It  is  probable  that  numerous  factors  are  en- 
gaged in  the  etiology  of  senile  arteriosclerosis  as  well  as  in  most 
pathological  forms.  There  is  the  underlying  cause  of  senile  invo- 
lution and  contributing  thereto  are  inherent  factors  as  heredity 
and  muscular  activity,  and  acquired  factors  as  smoking,  exces- 
sive meat  eating,  abuse  of  alcohol,  sexual  excesses,  etc.  The 
influence  of  heredity  cannot  be  satisfactorily  explained  and  it 
would  serve  no  purpose  to  dilate  upon  the  many  theories  that 
have  been  advanced  to  account  for  hereditary  influence.  The 
effect  of  muscular  activity  has  been  explained  by  the  presence 
in  the  blood  of  the  toxins  produced  by  muscular  activity,  by 
overstimulation  of  the  adrenals,  by  irritation  and  inflammation 
of  the  endothelium  through  the  greater  force  with  which  the 
blood  is  sent  from  the  heart,  and  by  more  rapid  exhaustion  of 
the  muscular  fibers  of  the  vessels. 

The  modus  operandi  of  autointoxication  in  the  production 
of  arterial  degeneration  is  unknown.  There  may  be  direct 
irritation  of  the  arterial  endothelium,  irritation  of  the  vaso- 
motor centers,  of  the  heart  or  adrenals,  impairment  of  the  pabu- 
lum, or  the  formation  of  minute  emboli  which  partially  block  the 
arterioles.  The  influence  of  alcohol  is  a  moot  question.  Edgren 
found  2  5  per  cent,  of  his  cases  traceable  to  alcoholism,  and  Herz 
obtaining  the  opinions  and  results  of  observation  from  about 
8oo  physicians  found  that  over  half  gave  alcohol  as  a  factor. 
On  the  other  hand,  many  physicians  reported  that  arteriosclero- 
sis was  very  rare  in  some  regions  where  alcohol  was  habitually 
used  even  by  women  and  children.  The  disease  is  found  among 
total  abstainers,  among  vegetarians  and  among  persons  who 
never  smoke,  while  many  aged  persons  with  a  comparatively  low 
blood  pressure  and  soft  arteries  drink,  smoke  and  eat  meat 
daily. 

Weil's  theory  may  be  mentioned  here  as  there  are  some 
favorable  reports  of  a  method  of  treatment  based  upon  this 
theory.  Weil  found  that  while  the  normal  daily  elimination  of 
CaO  through  the  kidneys  was  .39  grams,  in  over  50  per  cent,  of 
his  arteriosclerotic  cases  the  elimination  was  less  than  .2  grams 
and  in  no  case  did  it  reach  the  normal  notwithstanding  abundant 
lime  introduction.  The  conclusion  is  that  there  is  an  excessive 
lime  retention  with  consequent  disproportion  of  salts  in  the 


78  PATHOLOGICAL    OLD    AGE 

blood.  Lime  deposits  in  the  vessels  occur  late  in  the  disease  and 
this  theory  does  not  explain  the  early  degenerative  process.  It 
opens,  however,  a  new  field  for  speculation.  As  Weil's  obser- 
vations indicate  perverted  metabolism  similar  to  the  changed 
metabolism  in  gout  and  as  late  gout  is  marked  by  pathological 
deposits  of  calcareous  matter  in  joints  and  other  tissues  while 
late  arteriosclerosis  is  marked  by  similar  deposits  in  the  arterial 
walls  may  there  not  be  the  same  metabolic  disturbance  under- 
lying both  diseases?  The  clinical  picture  differs  according  to 
the  tissues  involved.  If  the  same  perversion  of  metabolism — by 
which  lime  is  retained  in  excess  of  the  needs  of  the  system  and 
deposited  in  abnormal  locations — is  responsible  for  both  gout 
and  arteriosclerosis,  the  same  treatment  ought  to  be  effective  in 
both.  The  causes  of  arteriosclerosis  can  be  placed  under  one 
of  three  heads :  causes  acting  by  irritating  the  lining  membrane, 
or  acting  primarily  upon  the  media,  or  acting  primarily  upon  the 
vasa,  vasorum  either  through  inflammation  or  through  dimin- 
ished blood  supply  from  contracted  arterioles  or  increased 
viscosity  of  the  blood. 

Nervous,  mental  and  emotional  stress  is  an  incidental 
factor  acting  probably  through  the  vasomotor  centers.  Most 
other  causes  are  toxemic,  either  bacteria,  or  endogenetic  toxins, 
products  of  disturbed  metabolism,  or  chemicals  introduced  from 
without.  Their  mode  of  action  has  been  suggested  under 
autointoxication. 

Arteriosclerosis  occurs  most  frequently  in  brain  workers, 
in  the  well-to-do  class,  in  women  before  the  fifty-fifth  year, 
and  in  men  after  that  age. 

Syphilis  and  lead  produce  a  degeneration  of  the  arterial 
walls  so  radically  different  from  the  ordinary  senile  arterio- 
sclerosis that  the  conidtion  resulting  from  these  causes  should 
receive  a  special  designation  such  as  syphilitic  degeneration  or 
lead  degeneration  of  the  arteries.  They  act  by  irritating  the 
lining  membrane. 

Pathology . — The  early  pathology  of  arteriosclerosis  depends 
upon  the  etiology  and  is  determined  by  the  location  of  the  initial 
lesion.  This  may  be  in  the  intima,  media  or  vasa  vasorum. 
If  the  disease  is  due  to  a  cause  producing  local  endothelial  irri- 
tation the  earliest  change  is  a  multiplication  of  cells  at  the  point 
of  irritation.     Patches  of  endothelium  thus  become  thickened 


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Obliterative  Endarteritis.  (77/e  tissue  from  which  drawing  was  made  was 
removed  from  near  a  cancer  of  the  face,  a>id  prepared  in  the  laboratory  of  the 
Jefferson  Medical  College  Hospital  by  Dr.  Thomas  Leidy  Rhoads.)  i-inch  objec- 
tive, i-inch  ocular.  Specimen  fixed  in  corrosive  sublimate,  infiltrated  with  par- 
affin, stained  with  hematoxylin  and  eosin,  and  mounted  in  balsam,  a.  Adventitia. 
b.  Media,  c,  c.  Elastic  lamina,  d.  Irregular  mass  of  organizing  tissue  superim- 
posed on  and  replacing  the  intima.  The  gross  specimen  was  hard,  cord-like,  but 
not  nodular. 


SENILE    ARTERIOSCLEROSIS 


79 


and  soon  undergo  granular  and  fatty  degeneration.  The  patch 
becomes  transformed  into  a  yellow,  opaque  nodular  mass  con- 
taining cholesterin,  fatty  granules  and  crystals,  and  is  separated 
from  the  blood  current  by  a  thin  pellicle.  This  atheromatous 
mass  diminishes  the  lumen  of  the  vessel.  In  some  cases  the 
patch  contains  little  fat  but  instead  a  mass  of  dark  brown  gran- 
ules and  broken-down  cells.  Later,  calcium  deposits  in  the 
patches,  first  forming,  in  combination  with  the  fat,  calcium 
soaps.  These  break  up,  the  calcium  combines  with  carbonic 
acid  and  phosphoric  acid  radicles  derived  from  the  blood  and 
thus  the  insoluble  calcium  carbonate  and  calcium  phosphate  are 
formed.  The  degeneration  proceeds  outward  involving  the 
connective  tissue,  which  hypertrophies,  and  the  elastic  and  mus- 
cular tissues,  which  waste.  In  most  cases  after  the  thickening 
of  the  endothelium,  whereby  the  caliber  of  the  vessel  is  dimin- 
ished, this  or  some  other  cause  interferes  with  the  free  passage  of 
blood  through  the  terminal  vessels,  the  vasa  vasorum  receive 
insufficient  blood  supply  and  the  main  vessel  is  consequently 
insufficiently  nourished.  This  causes  waste  of  the  highly  organ- 
ized muscle  fiber  and  hyperplasia  of  connective  tissue  which  re- 
quires less  blood  supply  than  the  muscle  structure.  Still  later, 
calcareous  deposits  occur  in  the  outer  coat,  the  deposits  occurring 
in  plaques  over  the  patches  of  the  inner  coat  or  are  diffused 
through  the  substance  of  the  vessel.  This  is  the  usual  course 
in  circumscribed  arteriosclerosis  and  forms  the  inflammatory 
type  of  the  disease.  The  second  or  mechanical  degeneration 
begins  in  the  media.  If  there  is  loss  of  tonicity  of  the  muscular 
fibers  through  overstretching,  the  vessel  becomes  tortuous  and 
dilated  and  the  current  is  slowed.  This  is  followed  by  a  compen- 
satory thickening  of  the  intima  through  proliferation  of  the  sub- 
endothelial  connective  tissue.  The  muscular  fibers  having  lost 
their  elastic  property  become  changed  and  they  degenerate, 
their  place  being  taken  by  fibrous  connective  tissue  which  also 
displaces  the  elastic  fibers.  Lime  deposits  occur  late  and  are 
diffused.  This  is  the  usual  process  in  senile  arteriosclerosis.  In 
small  vessels  the  caliber  may  be  diminished  through  overgrowth 
of  the  intima.  In  the  third  or  nutritional  type  of  degeneration 
there  is  more  or  less  rapid  degeneration  of  the  media  through 
insufficient  nutrition.  A  diminished  blood  supply  causes  rapid 
waste  of  muscle  and  elastic  fiber  leaving  minute  cavities  called 


8o  PATHOLOGICAL   OLD   AGE 

atheromatous  abscesses  and  allowing  small  aneurysmal  sacs  to 
form.  The  cavities  later  become  filled  with  granular  and  fatty 
debris.  An  increase  in  the  connective  tissue  now  takes  place 
and  the  walls  of  the  vessel  are  in  spots  thickened,  in  other  spots 
thin  and  liable  to  rupture.  Calcareous  deposits  occur  early  in 
the  broken-down  cavities. 

In  the  condition  described  by  the  French  as  Aortite  aigue, 
acute  aortitis,  there  is  an  inflammatory  condition  of  the  vessel 
beginning  at  the  point  where  the  blood  sent  out  from  the  left 
ventricle  impinges  upon  the  aortic  wall,  spreading  downward  and 
along  the  arch. 

Huchard  divides  arteriosclerosis  into  four  stages,  an  arterial 
stage,  cardioarteriosclerotic  stage,  mitroarterial  stage  and  cardi- 
ectatic  stage.  In  the  first  stage,  called  also  presclerotic  stage, 
the  toxins  in  the  blood  irritate  the  intima  and  by  extension  to  the 
media  cause  the  vessels  to  contract  thus  diminishing  their 
caliber.  The  heart  must  now  act  with  greater  force  to  send  the 
blood  through  the  contracted  vessels.  In  the  second  stage  the 
organic  changes  begin  in  the  arterial  walls  and  heart.  These 
are  followed  by  nephritic  changes  and  cerebral  disturbance.  In 
the  third  stage  the  heart  becomes  dilated  and  the  blood  pressure 
is  lowered.  In  the  last  stage  the  secondary  results  of  cardiac 
dilatation  appear  in  the  kidneys,  lungs,  liver,  etc.  There  is 
edema  of  the  extremities,  abdomen  and  lungs  and  passive  con- 
gestion  of   the   liver. 

Few  cases  of  arteriosclerosis  follow  these  stages  as  presented 
by  Huchard.  In  senile  cases  the  diminished  supply  of  blood 
may  produce  degenerative  changes  in  the  kidneys,  liver  and 
lungs  while  the  heart  shows  little  alteration  and  no  loss  of 
compensation. 

Symptoms. — The  earliest  subjective  symptoms  are  referable 
to  the  organs  and  tissues  affected  by  the  impaired  functions  of 
the  degenerated  vessels.  The  vessels  themselves  give  no  early 
symptoms.  When  the  disease  is  far  advanced  the  vessel  feels 
hard,  tense,  often  nodular  and  where  visible  it  appears  tor- 
tuous. Long  before  these  objective  manifestations  appear, 
the  subjective  symptoms  pointing  to  organic  disorder  will  call 
attention  to  the  disease.  The  symptoms  and  the  lesions  do  not 
always  correspond,  extensive  areas  of  arteriosclerosis  having 
been  found  after  death  which  gave  no  evidence  during  life,  and 


SENILE   ARTERIOSCLEROSIS  8 1 

in  some  cases  symptoms  usually  associated  with  some  form  of 
arterial  degeneration  made  life  miserable  yet  no  pathological 
condition  to  account  for  them  could  be  found  upon  autopsy. 

The  earliest  sign  of  arteriosclerosis  is  usually  increased  blood 
pressure  but  we  must  remember  that  high  blood  pressure  and 
arteriosclerosis  are  not  synonymous,  and  that  we  often  find 
arteriosclerosis  with  low  blood  pressure. 

The  normal  systolic  blood  pressure  in  old  age  can  be  approxi- 
mately determined  by  adding  the  age  to  one  hundred  m.m.  and 
allowing  a  leeway  of  about  5  per  cent,  above  and  below  the  sum 
of  the  two.  Many  persons  have  a  habitual  high  pressure  with- 
out other  sign  of  arterial  degeneration.  This  is  found  in  athletes 
and  those  who  do  hard  physical  labor.  The  blood  pressure  is 
raised  in  many  diseases  and  by  many  drugs,  without  impair- 
ment of  the  vessels.  The  diseases  and  drugs  which  raise  the 
blood  pressure  may  produce  arteriosclerosis  if  their  action  is  main- 
tained long  enough.  Indicanuria  is  not  a  symptom  of  arterio- 
sclerosis but  it  is  frequently  found  in  that  disease  and  whenever 
it  is  found  in  an  aged  individual  it  is  almost  certain  to  be  ac- 
companied by  high  blood  pressure  and  other  signs  of  arterial 
degeneration.  Bishop  has  shown  that  in  neurasthenia  there  is 
usually  a  low  blood  pressure  though  arteriosclerosis  may  be 
present.  It  is  probable  that  the  increased  blood  pressure  in 
nephritis  and  gout  is  due  to  the  increased  viscosity  of  the  blood 
whereby  it  passes  through  the  capillaries  with  greater  difficulty 
and  the  heart  action  must  be  increased  to  overcome  the  in- 
creased peripheral  resistance.  The  retention  of  lime  in  the  aged 
increases  the  viscosity  of  the  blood  and  this  contributes  to  raise 
the  blood  pressure  by  increasing  the  peripheral  resistance.  In 
addition  to  this,  there  is  usually  a  hypertrophied  heart,  apart 
from  the  atonicity  of  the  vessels.  A  diminished  amount  of 
blood  in  the  arteries  has  a  counteracting  influence  but  not  enough 
to  overcome  the  causes  of  increased  blood  pressure.  When  de- 
compensation sets  in  the  blood  pressure  falls. 

In  some  cases  the  earliest  sign  of  arteriosclerosis  is  seen  in  the 
tortuous  retinal  vessels.  Occasionally  the  normal  difference  in 
the  pulse  rate  when  standing  and  when  in  the  recumbent  posi- 
tion is  not  maintained.  If  the  pulse  is  more  frequent  in  the 
recumbent  position  the  disease  is  well  advanced.  The  disease 
may  be  suspected  if  the  rate  when  standing  is  less  than  six  over 

6 


82  PATHOLOGICAL    OLD    AGE 

the  pulse  rate  when  lying  down.  There  are  numerous  vague 
symptoms  of  nervous  origin  which  have  been  considered  sug- 
gestive of  approaching  arteriosclerosis  and  their  presence  has 
given  rise  to  the  opinion  that  there  exists  a  presclerotic  stage 
of  the  disease.  When  we  remember  that  the  normal  degenera- 
tion is  slowly  progressive,  that  there  is  a  progressive  increase  in 
blood  pressure  from  birth  and  that  the  normal  condition  is  a 
disease  condition  only  in  the  sense  that  it  produces  discomforts 
we  will  realize  the  impossibility  of  determining  at  what  point 
senile  arteriosclerosis  becomes  pathological,  or  of  denning  the 
so-called  presclerotic  stage.  Such  symptoms  as  headache  after 
smoking,  palpitation  upon  exertion,  sensory  disturbances,  etc., 
are  early  manifestations  of  localized  arteriosclerosis;  they  may, 
however,  be  due  to  other  conditions  than  arterial  degeneration. 
A  fairly  reliable  premonitory  sign  of  diffuse  arterial  degeneration 
is  an  intermittently  high  blood  pressure,  the  pressure  rising 
higher  from  ordinary  causes  producing. temporary  tension  than 
the  cause  itself  would  warrant.  In  a  typical  case  a  man  aged  sixty 
had  a  normal  systolic  pressure  of  1 60  mm.  upon  arising.  Walk- 
ing up  one  flight  of  stairs  raised  the  pressure  to  190  and  half  an 
hour  afterward  the  pressure  dropped  to  150.  There  was  no 
other  sign  of  cardiac  or  vascular  disease  but  six  months  later  the 
man  had  a  stroke  of  apoplexy. 

For  the  purpose  of  systematizing  the  manifold  symptoms 
of  regional  arteriosclerosis  the  disease  will  be  divided  into  central, 
including  the  heart  and  large  vessels;  visceral,  including  the 
viscera  and  the  vessels  supplying  them;  and  peripheral  arterio- 
sclerosis, including  arterioles  and  the  peripheral  vessels. 

Senile  endocarditis  and  the  various  cardiac  lesions  due  to 
arteriosclerosis  ought  to  be  included  in  the  central  group  but 
will  be  described  separately. 

Aortic  Arteriosclerosis. — Aortic  arteriosclerosis  is  the  most 
frequent  of  the  arterial  degenerations.  The  vessel  is  dilated,  its 
expansibility  is  diminished,  the  muscular  coat  is  replaced  by 
fibrous  tissue  and  there  are  fatty  or  calcareous  plaques  on  the 
inner  coat.  It  gives  no  distinctive  symptoms.  Occasionally 
an  increased  area  of  dullness  can  be  demonstrated,  there  is  some- 
times a  systolic  murmur  over  the  vessel  and  there  may  be  jugular 
pulsation.  If  the  arch  is  involved  the  pulsation  can  sometimes 
be  felt  behind  the  suprasternal  notch.     There  may  be  a  dif- 


Arteriosclerosis  of 
Abdominal  Aorta. 
(Satterwaite  Medical 
Record,  ;May  14,  1910.) 


Aorta,  Opened,  Showing  Different  Types  of  Atheroma. 
(From  Coplin's  "Manual  of  Pathology.")  The  surface  is 
most  extensively  altered  by  infiltration,  degeneration,  and 
necrosis.  Many  of  the  necrotic  areas  are  calcified  and  could 
be  fractured  by  bending.  A,  A,  A.  Elevated  obstructing 
patches  of  atheroma  surrounding  exit  points  of  small 
branches.     B,  B.  Linear  atheroma. 


SENILE    ARTERIOSCLEROSIS  83 

ference  in  the  character  of  the  carotid  pulse  on  the  two  sides.  A 
difference  in  the  character  of  the  radial  pulse  on  the  two  sides 
may  be  due  to  aortic,  subclavian,  brachial  or  radial  arterio- 
sclerosis. 

Acute  Degenerative  Aortitis. — This  occurs  most  frequently  in 
plethoric  individuals  showing  symptoms  of  cardiac  hypertrophy, 
palpitation  and  dyspnea.  The  symptoms  come  on  suddenly 
with  intense  dyspnea  resembling  a  severe  attack  of  spasmodic 
asthma,  a  pain  over  the  aorta,  anginal  in  character,  during  the 
attack,  and  a  constant  pain  or  ache  between  the  attacks.  In 
some  cases  the  first  attack  destroys  life,  more  often  the  patient 
succumbs  after  several  attacks. 

Aortic  Aneurysm. — Aortic  aneurysm  may  appear  as  a  mani- 
festation of  senile  arteriosclerosis,  although  it  occurs  more  fre- 
quently as  a  result  of  syphilitic  infection.  Occurring  as  a  primary 
disease  it  is  generally  spindle  shaped,  the  dilatation  involving 
all  the  walls  of  the  vessel.  Its  progress  is  slow  when  due  to 
senile  arteriosclerosis,  the  dilatation  proceeding  but  little  faster 
than  the  dilatation  of  the  rest  of  the  vessel,  and  the  walls  of 
the  aneurysm  continue  to  harden  with  the  walls  of  the  aorta 
above  and  below  it.  For  this  reason  it  never  attains  the 
size  of  the  syphilitic  aneurysm  nor  of  the  aneurysm  due  to 
traumatism  or  sudden  strain,  and  the  pressure  symptoms  that 
mark  the  other  forms  are  seldom  pronounced.  The  lesion  is 
most  frequently  at  or  just  above  the  root  of  the  ascending  por- 
tion of  the  aorta  and  is  recognized  more  often  by  the  physical 
signs  than  by  pressure  symptoms.  There  is  usually  a  palpable 
occasionally  a  visible,  pulsation  over  the  site  of  the  dilatation, 
dullness  on  percussion  and  a  systolic  murmur  carried  upward  to 
the  neck.  When  the  arch  is  involved  the  signs  are  most  pro- 
nounced behind  and  to  the  left  of  the  upper  part  of  the  sternum, 
and  when  in  the  descending  portion  the  signs  are  most  pronounced 
in  the  interscapular  space.  Bretschneider  reported  a  case  of 
sclerosis  of  the  arch  of  the  aorta  which  presented  as  one  of  the 
symptoms,  an  intermittent  dyskinesia  with  paroxysms  of  pain 
along  the  arm,  numbness  and  loss  of  contractility  of  the  muscles 
of  the  entire  upper  extremity. 

Coronary  Arteriosclerosis. — Sclerosis  of  the  coronary  arteries 
has  no  pathognomonic  symptoms.  The  only  symptom  which  is 
constantly  associated  with  this  condition  is  angina  pectoris,  but 


84  PATHOLOGICAL    OLD    AGE 

this  symptom  may  be  due  to  other  causes  and  coronary  sclerosis 
has  been  found  after  death  which  gave  no  symptoms  during 
life.  As  one  result  of  coronary  disease  is  malnutrition  of  the 
heart  with  consequent  muscular  degeneration,  the  symptoms  of 
such  degeneration  whether  fatty  infiltration,  fatty  degeneration, 
myofibrosis  or  brown  atrophy,  point  to  coronary  sclerosis.  The 
symptoms  associated  with  angina  pectoris  will  be  given  in  de- 
scribing this  disease  under  cardiac  neuroses.  The  presumptive 
diagnosis  based  upon  cardiac  asthma,  cardiac  degeneration  and 
angina  pectoris  amounts  almost  to  a  certainty. 

Arteriosclerosis  of  the  Pulmonary  Artery. — Arteriosclerosis  of 
the  pulmonary  artery  is  rare  and  the  diagnosis  is  difficult.  There 
is  generally  a  history  of  infection  with  mitral  stenosis  or  aortic 
insufficiency  and  arteriosclerosis  of  the  aorta.  The  symptoms 
are  cyanosis  without  dyspnea  or  edema,  and  pulmonary  hem- 
orrhage. The  physical  signs  are,  an  area  of  dullness  about  the 
upper  left  margin  of  the  sternum  sensitive  to  pressure  and  per- 
cussion, cardiac  dulness  increased  to  the  right,  the  diastolic 
thrill  and  the  presystolic  murmur  of  mitral  stenosis  above  and  to 
the  right  of  its  usual  location.  The  condition  may  be  diagnosed 
by  radiography. 

Arteriosclerosis  of  the  Abdominal  Aorta. — A  positive  diagnosis 
of  sclerosis  of  the  abdominal  aorta  can  be  made  only  when  the 
abdominal  walls  are  thin  and  the  artery  can  be  felt.  It  may  be 
possible  then  to  feel  nodules  or  areas  of  hardness,  or  irregularities 
in  the  impulse  given  to  the  fingers  by  the  pulsation  of  the  vessel. 
There  are  no  pathognomonic  symptoms  but  the  disease  may  be 
suspected  when  there  are  other  symptoms  and  signs  of  a  general- 
ized arteriosclerosis  and  vague,  painful  sensations  in  the  ab- 
domen increasing  at  times  to  agonizing  crises. 

Cerebral  Arteriosclerosis. — Cerebral  arteriosclerosis  gives  so- 
matic and  mental  symptoms.  The  earliest  of  the  somatic 
symptoms  is  a  dull  frontal  headache  most  severe  upon  arising 
and  passing  off  in  the  course  of  the  day.  This  headache  is  due 
to  a  passive  hyperemia  produced  by  the  recumbent  position, 
which  passes  away  when  the  patient  is  erect.  In  some  cases  the 
cerebral  hyperemia,  caused  by  the  recumbent  position  and  re- 
lieved by  the  erect  posture,  is  replaced  toward  evening  by  a 
gradually  increasing  cerebral  anemia  until  a  feeling  of  faintness 
compels   the  patient  to  lie  down.     Dizziness  and  vertigo  are 


SENILE    ARTERIOSCLEROSIS  85 

early  symptoms.  There  is  a  momentary  feeling  of  fulness  as 
though  a  gush  of  blood  came  up  from  below,  went  whirling  through 
the  head  then  just  as  suddenly  dropped  down  again.  This  is 
accompanied  by  a  flushing  of  the  face,  roaring  in  the  ears,  dim- 
ness of  vision  and  dulness  of  intellect.  The  whole  syndrome 
lasts  but  a  moment  and  disappears  completely.  As  the  disease 
progresses  the  symptoms  become  more  frequent  and  prolonged 
and  during  the  attacks  the  patient  becomes  unsteady  on  his  feet 
and  may  fall.  Numbness,  muscular  twitching,  weakness  of  the 
limbs,  trembling  and  disturbances  in  articulation  may  occur. 
Insomnia  is  a  frequent  accompaniment.  The  mental  disturb- 
ances are  alternating  depression  and  excitability,  illusion  and 
dementia.  The  illusions  are  not  insane  illusions  but  perverted 
perceptions  which  the  patient  recognizes  as  such.  Thus  asclero- 
sis  of  the  retinal  vessels  more  marked  on  one  side  may  give  two 
different  visual  impressions,  and  an  object  may  appear  double, 
distorted  or  with  a  halo  or  shadow  about  it.  There  may  be 
similar  auditory  perversion  producing  confused  sounds.  The 
patient  knows  that  these  are  illusions  and  ascribes  them  to  dis- 
ease of  the  eye  or  ear.  More  serious  are  the  mental  confusion 
and  delusions  which  occur  when  the  patient  becomes  excited  as 
these  may  persist  and  give  rise  to  anxiety  and  other  psychoses 
followed  by  melancholia  and  dementia. 

In  the  severer  forms  of  cerebral  arteriosclerosis  there  may 
be  transient  paralysis,  aphasia,  hemianopsia,  mental  aberra- 
tion, etc.,  passing  away  in  a  few  hours.  There  is  always 
danger  from  rupture  of  a  minute  vessel,  producing  apoplexy 
or  from  thrombus  or  embolus  with  consequent  rapid  cerebral 
degeneration. 

Ear  Symptoms. — The  ear  symptoms  begin  in  a  unilateral, 
later  bilateral,  tinnitus,  followed  by  slight  and  progressive  deaf- 
ness, loss  of  air  and  bone  conduction,  dizziness  and  auditory 
illusions  and  hallucinations. 

Eye  Symptoms. — The  arteriosclerotic  eye  shows  tortuous  reti- 
nal vessels,  and  occasionally  retinal  hemorrhages  due  to  in- 
creased tension  in  vessels  in  which  there  is  an  endarteritis.  There 
may  be  an  embolus  or  thrombus  of  the  central  artery  if  there  is 
cerebral  arteriosclerosis  and  then  the  vessels  are  anemic.  Usu- 
ally there  is  a  retinitis  if  the  arteriosclerosis  is  associated 
with  albuminuria,   embolism   or  thrombus  if  associated  with 


86  PATHOLOGICAL    OLD   AGE 

cerebral  or  cardiac  disease  and  atrophic  choroiditis  if  associ- 
ated with  disease  of  the  liver. 

Abdominal  Arteriosclerosis. — Degeneration  of  the  abdominal 
vessels  may  be  suspected  when  there  are  signs  of  diffuse  arterio- 
sclerosis and  symptoms  of  visceral  disturbances,  non-inflamma- 
tory in  character  with  progressive  impairment  of  function.  The 
symptoms  of  abdominal  arteriosclerosis  are  more  marked  in  al- 
lied organs  and  tissues  than  in  the  rest  of  the  body  and  as  the 
heart  is  usually  the  first  to  be  affected  by  impaired  circulation, 
the  kidneys  are  soon  involved.  The  kidney  is  frequently  found 
degenerated  yet  the  renal  artery  is  not  affected.  (This  will  be 
taken  up  under  senile  degeneration  of  the  kidney.) 

G  astro -intestinal  Arteriosclerosis. — The  symptoms  of  gastro- 
intestinal arteriosclerosis  are  manifold  and  appear  to  be  due  to 
impaired  nutrition  of  the  organs  and  irritation  of  the  abdominal 
sympathetic  nerves.  We  thus  get  two  sets  of  symptoms, 
functional  impairment  and  nerve  irritation,  the  latter  probably 
caused  by  some  toxic  substance  in  the  blood. 

The  early  diagnosis  of  this  condition  is  difficult,  as  the  organs 
affected  appear  to  be  the  original  seat  of  disease  until  other  symp- 
toms and  signs  of  arteriosclerosis  are  found.  There  is  usually  ab- 
dominal pain  about  the  umbilicus,  at  first  paroxysmal,  later 
continuous.  The  digestion  is  slowed  and  there  is  a  feeling  of 
oppression  in  the  stomach  for  several  hours  after  eating.  This  is 
due  to  dilatation  and  atrophic  catarrh  of  the  stomach. 

The  intestinal  symptoms  are  constipation,  flatulence,  met- 
eorism,  occasional  watery  or  bloody  diarrhea,  beginning  without 
apparent  cause,  lasting  for  a  few  hours  there  followed  by  con- 
stipation, sharp  pains  in  the  right  hypochondrium,  neuralgic  but 
not  colicky,  occurring  spasmodically  and  frequently  at  night. 
The  mesenteric  arteries  are  occasionally  atheromatous  but  they 
give  no  pathognomonic  symptoms.  Lagane  describes  an  arterio- 
sclerotic syndrome  of  the  intestines  but  the  symptoms  include 
many  that  are  clearly  due  to  other  pathological  conditions. 

Some  of  the  symptoms  of  abdominal  arteriosclerosis  resemble 
symptoms  of  tabes,  colic,  appendicitis,  lead  poisoning,  nervous 
dyspepsia,  neurasthenia,  or  other  neuroses.  In  nearly  all  doubt- 
ful cases  the  etiological  factors  will  clear  up  the  diagnosis. 

Hepatic  arteriosclerosis. — While  the  liver  generally  shows 
atrophic  degeneration  due  to  malnutrition  it  gives  no  signs  of  this 


Arteriosclerotic  Disease  of  the  Coronary  Artery  Giving  Rise  to 
Progressive  Obliteration  of  its  Lumen.  (From  Coplin's  ".Manual 
of  Pathology.")  Section  taken  from  sclerotic  periventricular  branch 
shown  in  Fig.  230.  The  elastic  lamella;  are  fragmented,  the  endothe- 
lium has  proliferated,  and  a  forming  thrombus  is  rapidly  occluding  the 
vessel.  .4.  Forming  thrombus  covered  at  most  points  by  endothe- 
lium. B.  Channel  through  thrombus  with  partial  wasting  of  ad- 
jacent vessel  wall.  C,  C.  Transverse  section  of  muscle-fibers,  show- 
ing fragmentation  and  retraction  from  the  myocardial  skeleton.  D. 
Unusually  conspicuous,  apparently  swollen  elastica;  the  same  change 
can  be  seen  in  many  parts  of  the  field.  The  fine  stipple  effect  in  the 
lower  part  of  the  figure,  and  especially  marked  in  the  lower  right,  is 
due  to  transverse  sectioning  of  elastic  fibers. 


E~  -mm 

lilr 


'  life 

Si 


Coronary  Artery,  Showing  Arterial 
"  Manual  of  Pathology.")  A .  Adventitia. 
Degenerating  newlv  formed  tissue  which  at 


Sclerosis.     (From.,  "Coplin's 

B.  Media.     C.  Intiina.     D. 

E  shows  advanced  softening. 


SENILE   ARTERIOSCLEROSIS  87 

condition  except  in  diminished  bile  supply,  the  bile  containing 
more  cholesterin  and  sometimes  producing  the  symptoms  of 
cholecystitis  and  cholelithiasis.  These  will  be  taken  up 
separately. 

The  pancreas  and  spleen,  on  autopsy,  are  often  found  de- 
generated, yet  give  no  clear  symptoms  during  life. 

Ortner's  Syndrome. — Ortner  describes  a  symptom  complex 
referable  to  the  stomach,  intestines,  heart  and  lungs.  These  are 
distress  after  eating,  distention  of  isolated  section  of  the  bowels 
with  intense  spasmodic  pain,  cyanosis  and  dypnea.  He  calls 
the  disease  "  Dyspragia  intermittens  angiosclerotica  intestinalis." 

A  rterio sclerosis  of  Spinal  Vessels. — The  dominant  symptoms  of 
arteriosclerosis  of  the  spinal  vessels  are  those  of  chronic  myelitis, 
occasionally  with  symptoms  of  multiple  sclerosis,  syringo- 
myelia, tabes  dorsalis,  or  general  paresis,  without  mental  im- 
pairment. In  rare  cases  there  is  a  compression  myelitis.  Paraly- 
sis agitans,  Charcot's  claudication  and  senile  tremor  are  sup- 
posed to  be  due  to  spinal  degeneration  following  arteriosclerosis 
of  the  vertebral  vessels,  but  these  conditions  are  sometimes 
found  in  cases  in  which  no  spinal  or  arterial  degeneration  could  be 
discovered.  In  Charcot's  claudication  there  is  an  intermittent 
lameness  following  prolonged  walking.  The  limb  feels  cold, 
there  is  rapid  numbness,  pain  and  sudden  inability  to  move  the 
limb.  This  passes  off  after  rest  but  will  return  upon  exercise  of 
the  limb.  In  this  form  of  claudication  the  step  is  normal,  but 
in  other  forms  the  step  may  be  unsteady,  short  and  tripping  or 
slow,  cautious,  and  long,  dragging  or  jerking. 

Peripheral  Arteriosclerosis. — In  peripheral  arteriosclerosis  the 
anatomical  and  functional  changes  occur  in  the  muscles  and  skin. 
There  is  a  sallowness  resembling  the  cancer  cachexia,  local  symp- 
toms of  numbness,  coldness,  tingling  and  other  paresthesias, 
cramps,  myalgia,  pruritus,  purpuric  eruptions  and  other  forms 
of  skin  disease.  Senile  gangrene  is  often  due  to  localized  arterio- 
sclerosis and  Raynaud's  disease,  when  occurring  in  the  aged,  is 
supposed  to  be  due  to  peripheral  arteriosclerosis  and  neuritis. 
Many  cases  of  senile  gangrene  give  a  history  of  local  syncope  and 
asphyxia  preceding  the  gangrene  and  are  really  cases  of  Ray- 
naud's disease  in  which  the  earlier  symptoms  were  neglected. 

Diagnosis. — The  protean  character  of  arteriosclerosis  and  the 
impossibility  of  differentiating  between  similar  visceral  symptoms 


88  PATHOLOGICAL   OLD   AGE 

due  to  this  and  to  other  causes  make  diagnosis  difficult  and 
errors  frequent.  After  the  hardening  of  the  radial  artery  has 
become  so  pronounced  as  to  be  recognized  by  the  finger,  the  diag- 
nosis is  evident,  but  by  this  time  the  disease  has  advanced  so  far 
that  nothing,  or  but  very  little  can  be  done  to  improve  the  con- 
dition. An  early  diagnosis  is  of  the  greatest  importance  and  in 
the  absence  of  pathognomonic  symptoms  we  must  consider  etio- 
logy, pathology,  and  general  symptoms  and  we  may  be  obliged 
to  depend  upon  the  result  of  treatment  to  prove  the  correctness 
of  our  diagnosis. 

In  senile  arteriosclerosis  the  principal  etiological  factor  is 
age.  Then  come  occupation  and  mode  of  life,  mental  labor 
favoring  cerebral  arteriosclerosis,  exciting  or  difficult  physical 
labor  predisposing  to  central  arteriosclerosis,  etc. 

Early  physical  signs  are  cardiac  hypertrophy,  accentuation 
of  the  second  sound  of  the  heart  and  high  blood  pressure.  In 
precocious  senility,  we  have  an  unfailing  sign  in  early  ossification 
of  the  costal  and  xiphoid  cartilages.  The  earliest  symptoms  will 
depend  upon  the  location  of  the  disease.  If  in  the  head,  headache 
upon  arising  and  occasional  vertigo  will  be  noticed.  In  the  arms 
or  legs  there  may  be  muscle  cramps  after  exercise.  In  making 
our  diagnosis  of  arteriosclerosis  of  an  abdominal  viscus  we  must 
be  guided  by  the  symptoms  and  signs  of  generalized  arterio- 
sclerosis. In  the  absence  of  such  symptoms  and  signs  if  the 
ordinary  treatment  for  the  local  conditions  is  ineffectual  a  single 
dose  of  nitrite  of  soda  or  nitroglycerin  may  clear  up  the  diagnosis 
by  giving  immediate  relief.  This  is  of  especial  service  in  the 
diagnosis  of  cases  involving  spinal  symptoms.  Many  of  the 
symptoms  given  above  may  be  due  to  antecedent  disease  to  which 
the  arteriosclerosis  is  secondary  and  it  is  not  unusual  to  have  the 
cause  for  secondary  arteriosclerosis  prevail  in  old  age.  It  is  thus 
possible  to  have  a  primary  senile  degeneration  and  a  secondary 
degeneration  of  the  arteries  following  syphilis,  gout,  and  infec- 
tious disease,  etc.,  prevail  at  the  same  time,  either  affecting  dif- 
ferent organs  or  one  aggravating  the  other. 

Prognosis. — The  prognosis  of  senile  arteriosclerosis  is  un- 
favorable. It  is  progressive  and  generally  destroys  the  indi- 
vidual either  through  exhaustion  of  the  heart  or  through  im- 
pairment of  some  other  organ  to  such  extent  as  to  prevent  its 
functions  or  through  cerebral  compression  following  cerebral 


iflss^9^;;.  ^';      -'  ^y^W^w^j&ijaiir 


Atheroma  of  Brachial  Artery.     (Pic  and  Bonnamour.) 


Radiogram   of  Arteriosclerosis  of  Internal  Iliac  Artery.     (Courtesy  of  Louis  Gregory 

Cole,  M.  D.     New  York.) 


SENILE   ARTERIOSCLEROSIS  89 

hemorrhage.  Occasionally  an  embolus  blocks  a  vessel  and 
prevents  the  nutrition  of  a  part  causing  its  rapid  degeneration,  or 
in  the  case  of  the  lungs  causing  fatal  dyspnea.  In  the  case  of 
embolism,  death  may  also  be  due  to  shock.  General  exhaustion 
due  to  profound  changes  in  the  organs  and  nerves  controlling 
metabolism  can  generally  be  traced  to  arteriosclerosis. 

The  progress  is  normally  slow  but  is  hastened  by  improper 
living,  poor  quality  of  food,  lack  of  exercise  and  vitiated  air. 
Cardiac  hypertrophy  keeps  pace  with  the  impairment  of  the 
circulation  due  to  degeneration  of  the  vessels.  With  the  limit 
of  hypertrophy  is  also  reached  the  limit  of  tonicity.  Further 
strain  results  in  broken  compensation  and  dilatation  and  this 
ends  in  cardiac  exhaustion. 

In  the  secondary  arteriosclerosis,  the  prognosis  will  depend 
upon  the  cure  of  the  primary  disease  and  the  activity  of  the 
metabolic  processes.  In  young  individuals  in  whom  the  ana- 
bolic processes  surpass  the  destructive  forces,  the  inhibition  of 
the  cause  and  elimination  of  waste  will  prevent  further  degenera- 
tion and  remove  the  pathological  tissue  which  will  be  replaced 
by  new  tissue.  In  senile  cases  the  metabolic  processes  proceed 
slowly,  and  as  the  repair  is  accomplished  through  the  blood 
which  is  deficient  in  quality  and  quantity,  a  lower  type  of  tissue 
is  formed  to  replace  the  degenerate  tissue.  In  this  way  the 
character  of  the  tissue  is  altered  through  the  proliferation  of 
connective  tissue  and  waste  of  normal  substance. 

Treatment. — Senile  arteriosclerosis  being  a  natural,  normal 
condition  is  incurable  in  the  sense  that  it  can  neither  be  pre- 
vented nor  removed.  The  best  that  we  can  hope  for  is  to  retard 
its  progress  and  relieve  disagreeable  symptoms. 

Before  beginning  treatment  we  must  be  certain  that  the  con- 
dition is  not  a  secondary  disease.  If  the  patient  has  ever  had 
syphilis,  acute  articular  rheumatism  or  gout,  though  the  symp- 
toms had  disappeared  years  before,  drug  treatment  applicable 
to  the  primary  disease  should  be  instituted.  In  these  cases  the 
iodides  are  serviceable.  It  does  not  matter  in  what  form  the 
iodine  is  introduced  whether  in  the  form  of  inorganic  salts  or 
organic  preparations  the  effect  upon  the  blood-vessels  and  the 
blood  is  the  same.  The  objection  to  the  iodide  of  potas- 
sium is  its  irritating  effect  upon  the  gastric  mucous  mem- 
brane.    This  is  not  as  pronounced  if  the  iodide  of  sodium  is 


90  PATHOLOGICAL    OLD    AGE 

used.  The  iodide  of  arsenic  in  i/i  5 -grain  doses  is  the  most  valu- 
able of  all  the  inorganic  iodine  compounds,  the  arsenic  being 
a  tonic  and  an  anabolic  stimulant.  It  is,  however,  eliminated 
slowly  and  produces  cumulative  toxic  effects.  If  it  is  employed, 
it  must  be  discontinued  as  soon  as  the  physiological  effects  of 
arsenic — gastric  irritation,  metallic  taste  or  swelling  under  the 
eyelids — appear.  Some  of  the  organic  iodine  preparations  do 
not  affect  the  stomach,  nor  do  they  produce  rashes,  nasal  or 
bronchial  catarrh  or  other  untoward  effects.  The  extravagant 
claims  made  by  the  manufacturers  of  these  organic  compounds 
deter  the  author  from  recommending  any  one  in  particular. 
The  iodides  should  never  be  used  if  there  is  high  blood  pressure 
and  low  viscosity  of  the  blood  as  the  iodides  still  further 
lower  the  viscosity  thereby  favoring  hemorrhage,  especially 
miliary  hemorrhages  from  the  cerebral  vessels.  Lime  salts 
are  positively  contraindicated  there  being  already  an  excessive 
retention  and  diminished  elimination  of  calcium.  In  senile 
arteriosclerosis  no  drug  will  permanently  improve  the  condition 
of  the  arteries.  Whatever  permanent  benefit  can  be  brought 
about  must  come  from  the  regulation  of  the  mode  of  life  of 
the  individual.  Drugs  must  however  be  employed  to  relieve 
the  disagreeable  concomitants  of  arteriosclerosis  either  by 
lowering  the  blood  pressure  or  by  local  treatment  of  the  part 
giving  the  disagreeable  symptoms. 

Many  drugs  will  lower  blood  pressure  yet  some  in  doing  so 
produce  direct  or  secondary  effects  more  serious  than  the  condi- 
tion they  are  intended  to  relieve.  Aconite,  gelsemium  and 
veratrum  viride  lower  blood  pressure  by  depressing  the  heart, 
weakening  its  force  and  slowing  its  action  thereby  diminishing 
the  blood  supply  to  organs  and  tissues  already  impaired  through 
insufficient  nutrition.  These  drugs  should  be  used  only  when 
there  is  a  rapid  and  full  pulse  not  due  to  nervous  causes  and  then 
they  should  be  combined  with  a  cardiac  stimulant  which  has 
no  vasoconstrictor  effect. 

The  choice  of  drug  to  diminish  the  blood  pressure  must 
depend  upon  its  action  upon  the  heart,  the  vessels  and  the  blood. 

The  favorable  action  of  the  iodides  is  due  to  the  property  of 
reducing  the  viscosity  of  the  blood,  thereby  allowing  the  blood 
to  flow  more  freely  through  the  contracted  vessels.  It  has  been 
suggested  that  they  stimulate  metabolic  activity  either  by  direct 


SENILE   ARTERIOSCLEROSIS 


91 


action  upon  degenerate  tissue  or  by  stimulation  of  the  thyroid 
gland.  They  are  useless  when  the  degeneration  is  part  of  the 
normal  process  of  involution  and  even  small  doses  will  produce 
the  physiological  effects,  iodism  with  rashes,  catarrhs  and  local 
irritation.  The  calcium  compounds  of  iodine  have  the  addi- 
tional disadvantage  of  increasing  the  viscosity  of  the  blood  and 
furnishing  an  excess  of  calcium. 

The  most  valuable  drugs  to  reduce  blood  pressure  are  the 
nitrites  which  act  by  dilating  the  arterioles.  In  angina  pectoris 
where  rapid  action  is  required  amyl  nitrite  used  by  inhalation 
produces  an  almost  instantaneous  effect,  lasting,  however,  but 
a  few  minutes.  Nitroglycerin  in  doses  of  one  or  two  minims  of 
a  1  per  cent,  solution  acts  almost  as  rapidly  when  given  hypoder- 
mically  and  somewhat  slower  when  given  by  mouth.  The  action 
lasts  about  fifteen  minutes.  The  nitrite  of  soda  in  grain  doses 
acts  in  fifteen  to  twenty  minutes  and  its  action  lasts  two  or  three 
hours.  Erythrol  tetranitrate  has  been  recommended  on  account 
of  its  more  prolonged  action,  but  it  possesses  no  other  advantage. 
It  is  given  in  ^-grain  doses.  The  dose  of  the  nitrites  depends  to 
a  great  extent  upon  the  tolerance  or  idiosyncrasy  of  the  patient 
and  the  condition  of  the  cerebral  vessels.  If  there  is  cerebral 
hyperemia  a  sudden  influx  of  blood  may  cause  rupture  of  a 
vessel.  The  long-continued  use  of  the  nitrites  may  cause  per- 
ipheral stasis  while  the  drugs  themselves  act  as  blood  toxins. 
Thyroid  extract  controls  high  blood  pressure  and  has  been  highly 
extolled  in  the  treatment  of  arteriosclerosis.  In  the  author's 
experience  small  doses  produced  distressing  palpitation  of  the 
heart  and  the  blood  pressure  rose  within  a  day  after  its  use 
was  discontinued. 

Theobromin  and  its  combinations  have  been  employed  to 
reduce  blood  pressure.  Huchard  recommends  its  use  as  it 
dilates  the  peripheral  vessels  and  stimulates  the  heart  and  the 
kidneys.  Diuretics  lower  blood  pressure  through  the  abstrac- 
tion of  fluid  from  the  circulation.  This,  however,  is  a  dis- 
advantage since  it  increases  the  viscosity  of  the  blood  and  the 
system  demands  restitution  in  thirst  which  cannot  be  ap- 
peased until  sufficient  fluid  has  been  imbibed  to  supply  the 
deficiency. 

Electrotherapeutists  report  reduction  of  blood  pressure 
through  high-voltage  currents,  but  this  method  of  treatment  is 


92  PATHOLOGICAL    OLD   AGE 

experimental  and  there  are  divergent  views  as  to  the  utility  of 
electricity  in  this  condition. 

Among  general  measures  employed  in  arteriosclerosis,  Trune- 
cek's  serum  deserves  attention.  This  is  a  solution  of  the  var- 
ious salts  in  the  proportion  in  which  they  are  found  in  the  plasma. 
The  theory  of  its  employment  is  based  upon  Weil's  theory  of 
disproportion  of  salts  in  the  blood,  Trunecek  arguing  that  by 
administering  the  plasma  salts  the  plasma  would  finally  hold 
the  normal  proportion,  any  excess  of  one  or  more  salts  being 
eliminated  by  the  kidneys.  It  is  believed  that  decalcification 
of  the  vessels  cannot  be  accomplished  by  chemical  means, 
and  consequently  such  result,  if  accomplished  at  all,  must  be 
brought  about  through  altered  metabolism.  This  is  the  only 
explanation  that  can  be  given  for  the  favorable  results  ob- 
tained in  many  arteriosclerotic  cases  treated  by  the  Trunecek 
serum  or  salts.  (The  salts  are  marketed  under  a  trade 
name.) 

In  treating  local  conditions  the  effect  of  drugs  rarely  lasts 
longer  than  the  period  of  effectiveness  of  the  last  dose.  If 
there  is  pain  morphine  will  relieve  it  but  if  the  cause  persists 
the  pain  will  return.  For  insomnia  5  to  10  grains  of  veronal 
may  be  given  at  bed  time  but  care  should  be  taken  that  the  blad- 
der is  emptied.  A  hot  foot  bath  in  the  morning  will  relieve  the 
morning  headache  and  a  whiff  of  ammonia  or  thirty  minims  of 
the  aromatic  spirits  of  ammonia  can  be  used  for  the  vertigo. 
The  attacks  of  vertigo  usually  last  but  a  moment  and  pass 
away  before  treatment  can  be  instituted.  Muscle  cramps  in 
the  limbs  will  disappear  if  hot  water  or  hot  cloths  are  applied 
and  the  same  treatment  will  generally  relieve  claudication. 
(Treatment  of  other  local  conditions  will  be  given  under  the 
description  of  such  conditions.)  Hygienic  and  dietetic  measures 
take  first  place  in  the  treatment  of  arteriosclerosis  as  the  dis- 
regard of  such  measures  is  mainly  responsible  for  this  disease  or 
its  early  appearance. 

The  most  important  rule  is  the  diminution  of  food  to  the 
amount  actually  required  to  maintain  strength,  the  elimination 
as  far  as  possible  of  purin-forming  protein  foods,  a  minimum  of 
lime-containing  foods  and  of  those  containing  much  cellulose 
and  other  indigestible  material.  The  amounts  should  not  be  left 
to  the  judgment  of  the  individual  but  it  should  be  regulated  as 


Arteriosclrosis  of  Posterior  Tibial   Artery.      (Courtesy  of  Lewis  Gregory  Cole,  M.  D., 

New  York.) 


SENILE   ARTERIOSCLEROSIS  93 

carefully  as  in  the  treatment  of  diabetes.  The  amount  of  tea 
and  coffee  should  be  cut  down  but  they  need  not  be  entirely 
eliminated.  Alcohol  is  injurious  yet  the  sudden  and  total  depri- 
vation of  alcohol  to  a  person  accustomed  to  it  will  produce 
mental  depression.  It  should  be  cut  down  gradually.  Beer 
is  worse  than  spirituous  liquors  while  light  dry  wines  are  the 
least  objectionable. 

The  loss  of  the  teeth  in  old  age  is  a  physiological  indication 
that  foods  requiring  thorough  mastication  are  unsuitable  and 
this  applies  especially  to  meat.  If  there  is  evidence  of  intes- 
tinal decomposition  in  foul-smelling  stools,  intestinal  antisep- 
tics are  required.  For  temporary  use  we  can  employ  salol, 
salicylic  acid  or  the  sulpho-carbolates.  For  prolonged  use  the 
lactic  acid  ferments  are  best.  When  the  disease  is  far  advanced 
and  there  is  broken  compensation  and  renal  difficulties  milk 
must  form  the  principal  article  of  diet.  Non-alcoholic  malt 
extract  is  a  valuable  adjunct  to  the  food  of  the  aged. 

It  is  hardly  necessary  to  insist  upon  a  daily  evacuation  of 
the  bowels. 

Many  writers  dilate  upon  the  injurious  effects  of  smoking 
yet  most  old  men  are  smokers.  Excessive  smoking  as  well  as 
excesses  in  other  things  is  injurious  but  it  need  not  be  forbidden 
entirely  unless  headache  or  vertigo  follows. 

Excessive  physical  exercise  should  be  forbidden  and  it  should 
be  an  imperative  rule  for  the  patient  to  rest  as  soon  as  he  begins 
to  feel  fatigued.  Further  exertion  can  be  carried  on  only  under 
a  forced  impulse  which  strains  the  heart,  increases  the  circulation 
abnormally  and  hastens  degeneration  of  the  vessels  and  organs 
involved.  A  sudden  exertion  or  intense  excitement  is  liable  to 
cause  paralysis  of  the  heart.  Mild  mental  and  physical  labor 
is  beneficial  before  myocardial  incapacity  has  set  in,  but  after- 
ward complete  mental  and  physical  rest  is  necessary.  In  the 
early  stage  active  elimination  of  toxic  material  by  catharsis, 
diuresis  and  diaphoresis  is  advisable.  Later  on  the  eliminative 
treatment  should  be  continued  but  not  forced  unless  local  con- 
ditions such  as  constipation  or  enuresis  make  it  necessary. 
Extreme  changes  in  temperature,  in  climate,  in  air  pressure 
as  when  going  from  the  seashore  to  the  mountains,  should  be 
avoided.  A  cheerful  spirit,  keeping  the  mind  pleasantly 
employed  and  free  from  worry,  and  the  kindly  ministration  of 


94  PATHOLOGICAL    OLD    AGE 

the  family  and  the  physician  often  do  more  to  relieve  the  dis- 
agreeable symptoms  than  drugs  or  other  measures. 

Amorphous  Phosphorus  in  Senile  Arteriosclerosis. — The 
author  has  used  the  red  amorphous  phosphorus  in  senile  arterio- 
sclerosis for  several  years.  Given  originally  as  a  substitute  for 
ordinary  phosphorus  in  senile  debility  it  was  found  that  it  was 
eliminated  as  amorphous  phosphate  of  lime  and  that  the  lime 
elimination  was  thereby  increased.  Weil's  experiments  showed 
that  the  lime  elimination  in  arteriosclerosis  was  diminished. 
Phosphorus  has  the  property  of  combining  with  lime  and  increas- 
ing the  lime  assimilation.  In  the  small  doses  which  can  be  given 
when  the  ordinary  phosphorus  is  employed  the  phosphorus 
will  combine  with  the  lime  of  the  food  and  increase  the  amount 
of  lime  salts  in  the  body.  When  given  as  amorphous  phos- 
phorus the  dose  is  two  grains  or  more  several  times  a  day,  and 
with  a  lime-free  diet  the  lime  required  for  the  combination 
necessary  to  secure  the  elimination  of  the  phosphorus  excess,  is 
drawn  from  the  abnormal  lime  deposits.  This  appears  to  be  the 
rationale  of  the  treatment  and  explains  the  good  results  obtained 
from  its  use. 


SENILE  PHLEBOSCLEROSIS 

Phlebosclerosis  is  a  degeneration  of  the  walls  of  the  veins 
analogous  to  the  degeneration  of  the  arterial  walls. 

Etiology. — A  primary  senile  degeneration  of  the  veins  is 
rare  and  occurs  almost  exclusively  in  veins  subjected  to  great 
pressure  such  as  the  veins  of  the  lower  extremities.  The  dis- 
ease generally  follows  a  phlebitis,  a  pyemia  or  an  infectious  dis- 
ease and  may  then  occur  at  the  site  of  the  phlebitis,  or  elsewhere. 
If  there  is  no  antecedent  disease,  the  degeneration  is  due  to 
impaired  nutrition  through  contracted  vasa  vasorum  as  occurs 
in  arteriosclerosis. 

Pathology. — Primary  degeneration  through  impaired  nutri- 
tion presents  similar  histological  changes  as  are  found  in  arterio- 
sclerosis. The  elastic  and  muscular  fibers  waste  and  permit 
dilatation  of  the  vesesl  and  the  production  of  varicose  veins. 
This  causes  slowing  of  the  current  with  production  of  thrombi 
in  the  pouches  of  the  varicosed  portions  of  the  vessels. 


SENILE    DEGENERATION    OF   THE   HEART 


95 


Symptoms. — Phlebosderosis  presents  no  marked  symptoms. 
Sometimes  areas  of  hardness  can  be  felt  along  the  course  of 
superficial  vessels,  ordinarily,  however,  the  symptoms  are  those 
of  varix.  If  lumps  are  felt  in  the  varix  dilations  they  are  usually 
due  to  thrombi.  A  thrombus  in  a  vessel  which  is  not  dilated, 
interferes  with  the  circulation  and  causes  local  edema,  becoming 
worse  and  accompanied  by  pain  upon  prolonged  standing.  A 
hypostatic  edema  of  the  ankles  and  feet,  frequently  met  with  in 
the  aged,  is  probably  due  to  phlebosderosis.  This  edema  is 
slight  except  after  prolonged  standing  or  walking.  The  physical 
fatigue  produced  by  such  exercise  necessitates  rest  and  thus 
any  great  accumulation  of  plasma  in  the  subcutaneous  tissue,  and 
the  discomfort  which  would  accompany  extensive  exudation,  is 
avoided. 

In  making  a  differential  diagnosis  of  phlebosderosis  from 
this  form  of  edema  we  must  eliminate  cardiac  and  renal  disease, 
anemia,  flatfoot  and  obesity.     It  may  occur  in  varicose  veins. 

Treatment. — There  is  no  treatment  for  phlebosderosis. 
The  treatment  for  venous  thrombus  and  varicose  veins  is  given 
under  varicose  veins.  For  the  edema  rest  and  rubber  ankle 
supporteis  will  give  relief,  but  the  condition  progresses  with 
the  cause. 

SENILE  DEGENERATION  OF  THE  HEART 

The  earliest  cardiac  change  due  to  age  is  cardiac  hypertro- 
phy. This  is  not  a  senile  change  but  the  ordinary  trophic  in- 
crease in  muscular  development  that  occurs  normally  in  all 
striped  muscles  actively  employed.  The  hypertrophy  caused  by 
the  greater  effort  of  the  heart  to  send  the  blood  through  vessels 
having  diminished  contractile  power  or  diminished  caliber, 
does  not  differ  from  the  hypertrophy  due  to  excessive  exercise 
in  earlier  life.  The  athlete's  hypertrophied  heart  remains 
enlarged  for  years  after  the  athletic  work  has  been  given  up  and 
may  become  a  permanent  condition.  The  hypertrophy  of 
the  senile  heart  is  confined  to  the  left  ventricle  until  the  valves 
are  involved. 

There  is  a  limit  to  muscular  capacity  and  when  this  has  been 
reached  further  activity  will  cause  muscle  exhaustion  or  degen- 
eration.    The  muscle  can  recover  from  exhaustion  upon  com- 


96  PATHOLOGICAL   OLD   AGE 

plete  rest  but  as  the  heart  cannot  absolutely  rest,  degeneration 
takes  place.  The  usual  degenerative  change  in  these  cases  is  a 
loss  of  tonicity  of  the  muscle  fiber  whereby  its  irritability  and 
contractility  are  diminished  and  it  stretches,  permitting  a  dila- 
tation of  the  cavity.  While  dilatation  of  the  heart  is  the  most 
frequent  sequel  of  cardiac  disorders  peculiar  to  the  aged,  it  is 
not  a  senile  degeneration  and  will  therefore  be  discussed  in  the 
fourth  group.  The  senile  myocardial  degenerations  are  myofi- 
brosis and  brown  atrophy,  the  former  occurring  most  frequently 
when  the  hypertrophied  heart  has  been  reached  the  limit  of  its 
functional  capacity  and  further  strain  causes  exhaustion, 
atonicity  and  degeneration.  Brown  atrophy  occurs  most  fre- 
quently in  hearts  that  have  not  been  greatly  hypertrophied, 
but  in  which  coronary  arteriosclerosis  appeared  early  and  inter- 
fered with  the  nutrition  of  the  organ.  Myofibrosis  is  therefore  a 
mechanical  degeneration,  while  brown  atrophy  is  a  nutritional 
degeneration.  Other  degenerations,  though  frequent  in  the 
aged,  are  not  strictly  senile  processes. 

Senile  Myofibrosis 

Senile  myofibrosis,  erroneously  called  chronic  myocarditis,  is 
a  degeneration  of  the  cardiac  muscle  marked  by  an  increase  of 
the  interstitial  connective  tissue  with  waste  of  muscle  fiber.  It 
corresponds  to  the  nutritional  type  of  arteriosclerosis.  It  is  the 
usual  form  of  senile  degeneration  and  in  its  milder  form  is  normal. 

Etiology. — Myofibrosis  is  due  to  impaired  nutrition  either 
from  some  fault  in  the  blood  or  from  diminished  supply  through 
coronary  sclerosis. 

As  myofibrosis  is  one  of  the  terminal  results  of  malnutri- 
tion whether  due  to  impaired  quality  of  the  blood  or  to  diminished 
quantity,  anything  which  will  cause  either  of  these  may  produce 
a  myocarditis  and  consequent  degeneration.  The  diminished 
blood  supply  causes  insufficient  repair  of  muscle  waste,  but 
there  is  sufficient  to  supply  hyperplastic  connective  tissue  which 
requires  less  nutrition  or  perhaps  the  blood  of  the  aged  contains 
more  of  the  nutritional  elements  required  by  the  connective 
tissue  and  less  of  the  elements  required  to  repair  muscle  waste. 
This  would  explain  the  general  tendency  to  fibrosis  in  old 
age. 


SENILE   MYOFIBROSIS 


97 


Satterthwaite  has  shown  how  an  embolus  from  chronic 
endocarditis  might  be  arrested  in  a  branch  of  the  coronary 
artery  and  produce  local  infarct  with  fibrosis.  Chronic  endo- 
carditis may  follow  an  acute  myocarditis,  endocarditis,  pericardi- 
tis, infectious  disease,  syphilis,  gout,  nephritis,  diabetes,  or 
alcohol,  lead,  or  tobacco  intoxication. 

Pathology. — Senile  myofibrosis  affects  the  whole  organ 
but  the  hyperplasia  is  most  marked  in  the  auricles.  In  the  early 
stage  of  the  disease  the  heart  is  usually  enlarged,  hypertrophied 
or  dilated,  later  as  the  muscle  waste  proceeds  it  becomes  smaller. 
There  is  an  increase  of  connective  tissue  and  a  waste  of  muscle 
fiber,  but  the  muscle  fibers  are  not  infiltrated  with  granular 
matter  as  occurs  in  myocarditis  following  infectious  diseases 
and  toxins.  They  may  present  segmentation  and  fragmenta- 
tion. The  heart  feels  harder  and  when  cut  across  it  looks  lighter 
in  color  than  normal.  The  valves  are  usually  affected  but  this 
may  be  due  to  a  senile  endocarditis  or  to  other  senile  changes. 
In  some  cases  there  is  in  addition  to  the  fibrosis  a  fatty  degenera- 
tion of  some  fibers.  It  is  not  known  what  particular  factor 
determines  the  character  of  the  degeneration,  fatty  or  fibrous, 
when  the  blood  supply  is  diminished.  As  there  is  in  both  the 
same  underlying  etiological  factor — insufficient  blood  supply — 
the  determining  factor  must  be  sought  for  in  the  blood  itself. 
Dilatation  is  a  frequent  sequel. 

Symptoms. — Senile  myofibrosis  produces  progressive  heart 
weakness.  The  force  of  the  contractions  is  diminished  and 
slight  causes  will  produce  arrhythmia  and  palpitation,  while 
intense  excitement  may  produce  delirium  cordis,  spasm  or  heart 
block.  In  the  mild  form  there  may  be  no  symptoms  except 
perhaps  palpitation,  vague  precordial  distress  and  dyspnea  upon 
slight  exertion,  but  these  symptoms  may  be  so  mild  as  to  pass 
unnoticed.  When  the  disease  is  further  advanced  there  is 
usually  a  weak  irregular  pulse  and  weak  apex  beat,  the  symptoms 
of  imperfect  aeration,  dyspnea  and  cyanosis  with  headache 
and  the  symptoms  of  cerebral  anemia,  facial  pallor,  blanched 
conjunctivas,  and  a  feeling  of  emptiness  in  the  back  of  the  head 
with  occasional  vertigo,  and  the  symptoms  of  surface  anemia, 
pale,  cold,  dry  skin.  Irritability  of  temper  is  frequent.  Other 
organs  become  affected  through  impaired  circulation,  insufficient 
blood   supply   and   passive   congestion.      Neurasthenia   occurs 

7 


98  PATHOLOGICAL    OLD    AGE 

frequently  and  angina  pectoris  occasionally,  due  to  coronary 
sclerosis. 

Diagnosis. — While  the  various  forms  of  cardiac  degeneration 
present  differences  in  their  pathology,  it  is  often  impossible  to 
distinguish  between  them  clinically.  In  many  cases  the  history 
will  determine  the  diagnosis.  Any  cause  which  will  produce 
an  acute  myocarditis  will  produce  a  chronic  myocarditis  with 
consequent  fibrosis.  The  acute  myocarditis  is,  however,  very 
rare  in  the  aged  and  is  almost  always  a  secondary  infection 
or  intoxication  most  frequently  following  an  influenza.  The 
chronic  myocarditis  is  secondary  to  acute  myocarditis  from 
toxin  or  gout,  rheumatism,  etc.  In  senile  myofibrosis  the  ante- 
cedent relations  are  cardiac  hypertrophy  and  coronary  arterio- 
sclerosis, the  former  causing  degeneration  through  overac- 
tivity and  consequent  exhaustion,  the  latter  through  malnu- 
trition. The  symptoms  of  acute  myocarditis  are  pain  and  a 
feeling  of  oppression  over  the  heart,  anxiety  and  a  fear  of  death, 
feeble  and  irregular  heart  action,  the  pulse  small,  irregular 
and  gradually  weakening.  In  chronic  myocarditis  the  symp- 
toms of  the  acute  form  appear  milder  and  more  persistent, 
there  is  dyspnea  and  later  cyanosis.  It  is  often  difficult  to 
differentiate  between  chronic  myocarditis  and  senile  myofibrosis 
except  by  the  history  and  by  the  course  of  the  disease.  Senile 
myofibrosis  is  progressive  and  while  its  progress  may  be  retarded 
it  cannot  be  halted  while  myocarditis  may  be  cured.  In  both 
diseases  the  symptoms  improve  after  prolonged  rest  but  in 
senile  fibrosis  the  heart  becomes  weak  again  after  exercise. 

Fatty  degeneration  produces  similar  symptoms  but  the 
heart  is  persistently  weak  while  in  fibrosis  the  heart  is  sometimes 
fairly  strong,  especially  after  prolonged  rest.  In  brown  atrophy 
the  size  of  the  heart  is  diminished  and  symptoms  of  coronary 
arteriosclerosis  are  frequent  while  in  myofibrosis  there  is  usually 
enlargement  of  the  heart  and  coronary  symptoms  are  infrequent. 

Treatment. — The  treatment  of  senile  myofibrosis  must  be 
hygienic  and  symptomatic.  The  condition  is  slowly  progressive 
and  we  can  do  nothing  to  arrest  its  progress  nor  to  restore 
degenerate  tissue.  The  symptoms  are  usually  so  mild  that 
they  are  neglected  by  the  patient  and  are  but  mentioned  inci- 
dentally when  complaining  of  the  more  distressing  symptoms 
of  some  other  disease.     (The  treatment  of  the  incidental  symp- 


Arteriosclerosis  of  Peroneal  Artery.     (Courtesy  of  Lewis  Gregory  Cole,  M.  D.r 

New  York.) 


BROWN  ATROPHY  OF  THE  HEART 


99 


toms  arrhythmia,  palpitation  and  angina  pectoris  will  be  given 
under  Cardiac  Neuroses.) 

When  cardiac  weakness  becomes  marked  the  most  important 
measure  is  rest.  Digitalis  is  contraindicated  as  the  degenerated 
fibers  cannot  respond  and  the  excessive  work  imposed  upon  the 
healthy  fibers  causes  their  rapid  degeneration  while  its  vasocon- 
strictor action  further  diminishes  the  blood  supply  to  the 
heart  by  contracting  the  coronaries.  Where  there  are  marked 
symptoms  of  cerebral  and  peripheral  anemia  the  nitrite  of  soda 
in  i/6-grain  to  i -grain  doses  four  times  a  day  should  be  given. 
Alcohol  in  the  form  of  whiskey  or  wine  given  with  meals  is 
often  beneficial.  Late  in  the  disease  camphor,  cafTein,  strychnin 
and  strophanthin  may  become  necessary.  In  regulating  the 
life  of  the  patient  the  avoidance  of  sudden  strain  is  of  the  greatest 
importance.  Even  straining  at  stool  is  injurious  and  may 
cause  sudden  cardiac  exhaustion.  A  profound  emotion  may 
do  the  same.  Some  exercise  is  necessary  but  it  must  not  pro- 
duce fatigue  or  strain  and  it  must  be  stopped  as  soon  as  dyspnea 
or  palpitation  appear.  The  rarified  air  of  the  highlands  is 
detrimental.  The  Schott,  Nauheim  and  Oertel  treatment  are 
dangerous  and  should  not  be  used  in  senile  cases  notwithstand- 
ing favorable  reports  from  those  interested  in  institutions  giving 
such  treatments. 

Dietary  restrictions  are  directed  principally  to  non-constipat- 
ing foods.  Sexual  excitement  should  be  avoided.  (The  treat- 
ment for  coronary  arteriosclerosis  is  given  under  Arteriosclerosis.) 

Brown  Atrophy  of  the  Heart 

Brown  atrophy  is  an  infrequent  physiological,  atrophic 
condition  of  the  senile  heart.  It  must  be  observed  that  degenera- 
tion of  the  heart  muscle  occurs  normally  much  later  than  the 
degeneration  in  other  organs  and  tissues  and  upon  autopsy  of 
aged  individuals  we  frequently  find  no  cardiac  change  other 
than  hypertrophy  or  dilatation  with  the  accompanying  valvular 
lesions  and  perhaps  a  senile  endocarditis. 

Etiology. — It  occurs  normally  if  there  is  a  slowly  develop- 
ing coronary  arteriosclerosis  without  marked  hypertrophy.  It 
has  been  found  also  in  younger  individuals  who  were  suffering  from 
prolonged  toxemias,  tachycardia  and  overwork. 


IOO  PATHOLOGICAL   OLD    AGE 

Pathology. — In  brown  atrophy  the  heart  is  diminished  in 
size  and  there  is  little  or  no  hyperplasia  of  connective  tissue. 
The  muscle  cells  are  atrophied  and  there  is  a  deposit  of  brownish 
pigment  about  the  nuclei.  The  muscle  striations  become 
obscure  but  segmentation  and  fragmentation  does  not  occur. 
The  heart  is  of  a  dark  brown  color  and  may  appear  shrunken 
and  withered  with  the  vessels  brought  out  in  relief. 

Symptoms. — The  symptoms  are  those  of  cardiac  weakness. 
There  is  a  weak  apex  beat  and  weak  pulse  becoming  irregular  in 
rhythm  and  force  upon  exertion  or  excitement.  At  such  times 
there  are  also  dyspnea  and  palpitation  and  the  patient  becomes 
irritable.  In  advanced  cases  there  are  the  symptoms  of  imper- 
fect aeration,  cerebral  and  peripheral  anemia,  and  functional  im- 
pairment of  other  organs  and  tissues  through  impaired  circula- 
tion and  passive  congestion.  The  symptoms  are  the  same  as  in 
other  forms  of  myocardial  degeneration  and  the  diagnosis  will 
depend  upon  the  diminished  area  of  cardiac  dulness,  the  age 
and  the  exclusion  of  other  causes  of  cardiac  atrophy,  starvation 
and  wasting  diseases.  The  atrophic  stage  of  senile  fibrosis  oc- 
curs late,  perhaps  years  after  the  earlier  symptoms  called  atten- 
tion to  this  condition. 

Treatment. — What  has  been  said  of  treatment  under  senile 
fibrosis  applies  to  brown  atrophy.  Hygienic  measures,  especially 
the  avoidance  of  physical  exertion,  strong  emotions  and  excite- 
ment are  more  important  than  drugs. 

SENILE  ENDOCARDITIS 

This  form  of  chronic  endocarditis  is  a  senile  degeneration  of 
the  endocardium  and  is  usually  part  of  a  general  arteriosclerosis. 
It  cannot  be  differentiated  except  etiologically  from  the  chronic 
endocarditis  that  follows  the  acute  form  and  from  the  sclerotic 
endocarditis  that  is  induced  by  alcohol,  syphilis,  autogenous 
toxins,  excessive  exercise,  etc. 

Etiology. — When  part  of  a  general  arteriosclerosis,  there 
are  the  same  etiological  factors  (see  senile  arteriosclerosis).  In 
rare  cases  there  is  an  extension  of  the  sclerotic  process  from  the 
aorta  to  the  aortic  valve  and  to  the  left  ventricle. 

Pathology. — The  changes  in  the  endocardium  are  like  the 
degenerative  changes  in  the  endothelial  layer  of  the  blood-vessels. 


SENILE   DEGENERATION   OF   THE   LUNGS  IOI 

The  membrane  becomes  thickened  and  firmer,  there  is  frequently 
a  covering  layer  of  fibrin  over  atheromatous  patches  and  occasion- 
ally calcareous  plates  are  found.  The  changes  are  most  pro- 
nounced about  the  valves  which  become  thickened  and  misshapen 
and  lose  their  elasticity.  The  cordae-tendinae  become  sclerosed. 
The  aortic  valve  is  most  frequently  involved,  the  structural 
changes  producing  insufficiency. 

Symptoms. — This  condition  cannot  be  diagnosed  until  the 
valves  are  involved,  when  the  symptoms  of  valvular  disease 
appear.  There  may  be  occasional  precordial  distress ,  arrhythmia, 
palpitation,  etc.,  but  nothing  distinctive  upon  which  to  base  a 
diagnosis. 

Treatment. — The  treatment  depends  upon  the  valvular 
disease  that  is  produced. 


SENILE  DEGENERATION  OF  THE  LUNGS 

Senile  atrophy  of  the  lung  is  a  physiological  condition, 
but  it  may  produce  so  much  distress  as  to  require  medical 
intervention. 

Etiology. — A  number  of  causes  combine  to  bring  about  pul- 
monary degeneration.  Apart  from  theoretical  causes,  tissue- 
cell  evolution  and  a  change  in  the  character  Of  the  blood,  arterio- 
sclerosis of  the  pulmonary  vessels  diminishes  the  quantity  of 
blood  sent  through  the  lungs.  Pneumokoniosis  stimulates 
connective-tissue  hyperplasia  and  the  contraction  of  this  fibrous 
tissue  compresses  the  lung  tissue.  The  lungs  are  further  com- 
pressed by  the  rigidity  of  the  chest  walls.  There  is  then  in- 
sufficient nutrition  and  mechanical  compression,  causing  waste 
of  tissue. 

Pathology. — The  lung  undergoing  senile  degeneration  is 
smaller  than  in  maturity,  discolored,  and  on  section  presents 
minute  cavities.  These  are  due  to  the  waste  of  the  alveolar  septa 
whereby  the  air  cells  coalesce  and  the  condition  called  small 
chest  or  senile  emphysema  is  produced.  The  residual  air  is  in- 
creased, the  vital  capacity  is  diminished  and  both  inspiration 
and  expiration  are  lessened. 

Symptoms. — The  symptoms  of  senile  degeneration  of  the 
lungs  become  distressing  when  there  is  marked  emphysema. 


102  PATHOLOGICAL    OLD   AGE 

The  diminished  respiration  and  lessened  aerating  surface  cause 
incomplete  aeration  of  blood  and  consequent  cyanosis  but  this 
produces  very  little  or  no  distress.  The  real  distressing  symp- 
tom of  pulmonary  degeneration,  "dyspnea,"  is  due  to  senile 
emphysema. 

Senile  emphysema  differs  from  the  emphysema  of  maturity 
in  the  absence  of  the  barrel-shaped  chest  which  is  almost  pathog- 
nomonic of  this  disease  in  earlier  life.  In  the  senile  form  the  chest 
walls  are  rigid,  there  is  no  respiratory  expansion  and  the  respira- 
tion is  carried  on  mainly  by  the  diaphragm.  When  the  dyspnea 
is  severe,  there  is  a  raising  and  dropping  of  the  entire  thorax, 
the  supra-  and  infraclavicular  spaces  sink  and  the  muscles  of  the 
neck  are  prominent.  Percussion  shows  that  the  lungs  lie  lower 
than  in  maturity,  the  apex  is  lower  and  the  percussion  here  is 
indistinct.  The  percussion  note  in  senile  emphysema  is  peculiar, 
there  being  a  typanitic  resonance  without  the  momentary 
echo  sound  that  accompanies  the  hyperresonance  of  ordinary 
emphysema.  Upon  auscultation  we  get  a  weak  vesicular  mur- 
mur with  prolonged  expiratory  note.  If  the  patient  has  been 
lying  upon  his  back,  immediately  upon  arising  dry  crepitant 
rales  can  be  heard  at  the  lower  part  of  the  back  during  the  first 
few  inspirations.  This  is  due  to  the  opening  of  the  air  vesicles 
in  that  part  of  the  lungs,  which  were  compressed  in  the  recum- 
bent position  and  is  a  pathognomonic  sign  of  this  condition. 

Moist  rales  are  due  to  bronchitis.  The  latter  if  present  is 
not  associated  with  senile  emphysema  as  in  other  forms  of  em- 
physema, but  is  an  accidental  complication.  The  dyspnea  of 
senile  emphysema  is  both  inspiratory  and  expiratory,  the  latter 
more  pronounced.  In  the  early  stage  it  appears  only  upon  ex- 
cessive exertion,  later  slight  exertion  as  walking  up  a  few  steps, 
may  bring  it  on.  When  this  occurs  there  is  extensive  involve- 
ment of  the  lungs,  with  cyanosis  and  cardiac  disease.  Usually 
senile  emphysema  gives  no  symptoms  until  the  disease  is  far 
advanced,  as  the  physical  condition  of  the  individual  prevents 
him  from  undertaking  difficult  tasks  which  might  cause  dyspnea. 

Treatment. — Prophylactic  measures  can  be  employed  to  defer 
the  atrophy  of  the  lungs.  A  cane  should  be  used  as  soon  as  it 
is  noticed  that  the  ageing  individual  walks  with  a  stoop.  Shoul- 
der braces  are  useful  but  irksome.  Deep  breathing,  taking  a 
long,  steady  deep  breath  should  be  practiced  several  times  a  day. 


0 

- 


- 


PNEUMOKONIOSIS 


IO3 


When  seated,  the  person  should  use  an  arm  chair  and  keep  his 
arms  upon  the  rests.  A  warm,  dry,  equable  climate  at  low  ele- 
vation and  free  from  dust  is  the  most  important  hygienic  meas- 
ure. Mild  exercise  is  beneficial  but  fatigue  must  be  avoided. 
The  individual  should  change  his  position  frequently,  alternating 
between  walking,  standing,  sitting  and  lying  down.  Bella- 
donna is  useful  as  a  stimulant  to  the  respiratory  centers  and 
oxygen  inhalation  for  cyanosis. 


PNEUMOKONIOSIS 

Pneumokoniosis  or  fibrous  induration  of  the  lung  is  caused 
by  the  constant  inhalation  of  dust. 

Etiology. — Dust  is  inhaled  in  the  air  stream  from  birth. 
Most  of  the  dust  is  caught  by  the  ciliated  epithelium  of  the 
bronchi,  but  some  reaches  the  alveoli  and  works  its  way  or  is 
possibly  carried  by  phagocytes  into  the  lymph  spaces  and  con- 
nective tissue,  causing  a  chronic  irritation  with  consequent 
hyperplasia  of  such  tissue.  Some  induration  from  this  cause  is 
found  in  every  aged  individual.  It  is  more  pronounced  among 
city  dwellers,  especially  in  manufacturing  towns  in  which  there 
is  much  soot  and  dust  in  the  atmosphere,  and  occurs  to  but  a 
slight  extent  in  sailors  of  sailing  vessels. 

Pathology. — The  lungs  are  discolored,  the  pigment  ranging 
from  gray  to  black,  depending  upon  the  character  and  quantity 
of  dust  that  had  been  inhaled.  This  discoloration  may  be  uni- 
form throughout  the  lungs  or  appear  in  scattered  areas  giving 
the  lung  a  mottled  appearance.  There  is  a  hyperplasia  of  con- 
nective tissue,  the  new  tissue  being  pigmented.  Dust  particles 
may  be  found  in  the  alveolar  epithelium.  As  hyperplasia  of 
connective  tissue  occurs  normally  in  the  process  of  involution, 
it  is  probable  that  the  fibrous  induration  generally  found  in  senile 
lungs  is  part  of  this  normal  degeneration,  while  the  slow  accumu- 
lation of  dust,  acting  as  an  irritant,  plays  but  a  small  part  in  the 
proliferation  of  the  connective  tissue.  Senile  pneumokoniosis  is 
almost  invariably  associated  with  atrophic  emphysema,  the  two 
producing  the  typical  atrophied  lung  of  senility. 

Symptoms. — The  slow  progressive  pneumokoniosis  of  old  age, 
which  has  not  been  aggravated  by  vocational  dust  inhalation, 


104  PATHOLOGICAL   OLD   AGE 

gives  no  marked  symptoms,  except  perhaps  a  hypertrophic 
bronchitis.  The  emphysematous  symptoms  which  occasionally 
accompany  it  are  due  to  the  senile  emphysema.  The  sputum  is 
gray,  tenacious  and  thick,  containing  leucocytes  and  cells  from 
the  bronchial  and  alveolar  membranes  with  enclosed  dust 
particles.  Those  suffering  from  the  vocational  forms  of  pneu- 
mokoniosis,  like  miners,  knife  grinders,  glass  and  metal  en- 
gravers, sand-blast  operators,  stone  cutters,  etc.,  rarely  reach  old 
age,  as  the  dust  particles  which  they  inhale  are  sharp,  cut  into 
the   tissues,   cause   necrosis   and   produce   cavities. 

Pneumokoniosis  is  sometimes  called  primary  chronic  in- 
terstitial pneumonia.  The  latter  disease  is  generally  localized 
and  unilateral,  and  there  is  no  discoloration  of  tissue.  Septic 
infection  frequently  occurs  and  results   in  gangrene. 

Treatment. — Pneumokoniosis  is  incurable.  If  there  are  dis- 
tressing symptoms,  such  as  dyspnea  or  excessive  expectoration, 
the  treatment  must  be  directed  to  the  emphysema  or  bronchitis 
which  causes  the  symptoms.  The  patient  should  be  removed 
from  the  smoky  or  dust-laden  atmosphere,  preferably  to  the 
seashore.  If  an  aged  person  suffering  from  bronchitis  moves 
from  the  clear  atmosphere  of  the  country,  to  a  smoky  city,  dis- 
tressing symptoms  rapidly  follow. 


SENILE  DEGENERATION  OF  THE  ORAL  CAVITY 

The  degenerative  changes  in  the  mouth  and  pharynx  are  not 
marked  except  by  the  loss  of  the  teeth,  yet  this  has  a  marked 
influence  upon  the  health  and  welfare  of  the  individual. 

The  teeth  crack  and  break,  their  nerves  and  blood-vessels 
atrophy  and  with  the  atrophy  of  the  alveolar  process  the  teeth 
become  loose  and  fall  out.  The  mucous  coating  of  the  mouth 
becomes  thin  and  pale,  the  glands  atrophy,  and  likewise  the 
salivary  glands.  The  secretions  are  diminished  but  not  altered. 
The  change  in  the  shape  of  the  inferior  maxilla  is  the  most  marked 
osseous  senile  change  in  the  body.  The  muscles  of  mastication 
and  deglutition  waste  and  lose  their  tonicity.  Owing  to  the  loss 
of  the  teeth  and  the  waste  of  muscles  a  decided  effort  must  be 
made  to  approximate  the  gums  and  for  this  reason  the  jaws  are 
never  brought  together  except  by  a  special  effort  of  the  will 


SENILE   DEGENERATION   OF   THE   ORAL   CAVITY  105 

although  the  lips  may  be  closed  easily.  In  some  cases  the 
openings  of  the  salivary  ducts  are  dilated  permitting  a  dribbling 
of  saliva  into  the  mouth  and  if  the  lips  are  flaccid  and  not 
tightly  closed  the  saliva  drips  out.  As  a  result  of  these  changes 
and  of  evident  changes  in  the  nerves  and  taste  bulbs  which 
have,  however,  never  been  demonstrated,  profound  changes 
occur  in  mastication  and  deglutition,  in  the  appetite  and  in 
buccal  digestion. 

The  loss  of  the  teeth  prevents  mastication  and  necessitates 
a  change  in  diet,  the  most  important  dietary  change  being  the 
elimination  of  meat.  While  the  loss  of  teeth  can  be  repaired 
artificially,  making  the  elimination  of  meat  apparently  un- 
necessary, this  loss  in  the  healthy  aged  person  seems  to  keep 
pace  with  the  senile  degeneration  of  the  stomach.  Owing  to 
degeneration  of  that  organ  meat  digestion  becomes  more  diffi- 
cult and  it  would  seem  that  the  loss  of  teeth  is  really  a  natural 
provision  to  prevent  excessive  work  for  the  senile  stomach. 
Diminished  appetite  has  probably  the  same  purpose,  lessening 
the  amount  of  the  ingesta  in  proportion  to  the  needs  of  the  sys- 
tem and  to  the  diminished  activity  of  the  excretory  organs. 
Senile  dysphagia  is  part  of  the  same  natural  provision  to  prevent 
overfeeding.  The  individual  must  make  a  sensible  effort  to 
swallow.  Solids  pass  more  readily  than  liquids;  acid,  sour, 
sharp,  and  acrid  substances  are  swallowed  more  easily  than 
alkaline,  sweet  and  insipid  substances.  Lessened  thirst  is  prob- 
ably due  to  a  dulling  of  the  sensibilities  of  the  nerve  terminals 
and,  like  diminished  appetite,  is  a  compensatory  arrangement 
to  give  less  work  to  the  heart  and  kidneys. 

Nothing  can  be  done  for  the  dysphagia  and  nothing  need  be 
done  for  the  other  conditions  except  for  the  drivel  of  saliva. 
It  is  sometimes  possible  to  instil  a  sense  of  neatness  in  the  indi- 
vidual so  that  he  will  make  an  effort  to  control  it.  If  this  fails 
it  may  be  possible  to  control  it  by  local  astringent  applications 
to  the  mouths  of  the  ducts.  There  is,  however,  danger  of  pro- 
ducing stenosis  with  complete  drying  and  atrophy  of  the  glands, 
a  far  more  serious  condition  than  the  drivel.  Atropia  is 
contraindicated . 

Glossodynia  occurs  occasionally  and  is  probably  due  to  the 
degeneration  of  the  nerve  terminals  in  the  tongue.  It  is  a 
paresthesia  which  does  not  yield  to  local  treatment. 


106  PATHOLOGICAL   OLD   AGE 

SENILE  DEGENERATION  OF  THE  STOMACH 

While  the  anatomical  changes  of  the  stomach,  due  to  the 
process  of  ageing,  are  marked,  the  functional  impairment  is 
slight,  the  demands  made  upon  the  senile  organ  being  less.  In 
senile  tissue  generally,  the  functions  are  performed  less  actively 
or  differently  from  those  of  maturity  but  harmonious  relations 
are  maintained  with  allied  organs  and  tissues,  the  functions  of 
which  are  likewise  impaired,  thus  maintaining  the  body  in  the 
state  of  functional  equilibrium.  This  applies  with  special  force 
to  the  stomach  in  which  digestion  is  carried  on  sufficient  for  the 
needs  of  the  aged  organs  while  the  same  anatomical  condition 
occurring  in  maturity  would  cause  serious  disturbance.  There 
are  several  natural  provisions  for  shielding  the  stomach  in  old 
age  from  excessive  work.  There  is  usually  diminished  appetite 
due  to  lessened  need  for  food  and  to  obtunded  sense  of  hunger. 
Owing  to  the  loss  of  teeth  the  aged  individual  cannot  chew  meat 
and  he  will  take  instead,  eggs,  milk  and  vegetable  proteids  which 
are  more  readily  digestible.  He  has  a  distaste  for  flat  and  in- 
sipid foods  and  prefers  salty  and  acid  ones.  The  flat-tasting 
food  is  generally  alkaline  and  as  there  is  in  old  age  a  diminution 
in  the  quantity  of  hydrochloric  acid,  alkaline  food  interferes  with 
digestion. 

The  prominent  manifestations  of  senile  degeneration  of  the 
stomach  arise  from  atony  and  waste  of  the  muscular  fibers, 
diminution  in  the  quantity  of  gastric  juice  and  hydrochloric  acid 
and  atrophy  of  the  mucous  membrane.  As  a  result  of  these  senile 
changes  we  have  atonicity  and  dilatation  of  the  stomach,  weakened 
propulsive  power,  prolonged  retention  of  food,  slow  digestion 
of  proteids  and  occasionally  also  insufficiency  of  the  pylorus. 
Dietetic  indiscretions  will  produce  acute  indigestion  and  gas- 
tric asthma  and  if  prolonged,  a  chronic  senile  catarrh  will  result 
which  may  predispose  to  cancer. 

Gastric  Atonicity 

Etiology. — Owing  to  the  loss  of  tone  of  the  muscular  fibers  the 
peristaltic  waves  are  slower,  the  wave  ring  of  circular  fibers 
does  not  contract  as  powerfully,  contractions  of  the  cardiac 
portion  are  also  slower  and  less  powerful  and  food  is  not  propelled 
as  rapidly  toward  the  pylorus  nor  is  the  food  mixed  as  thoroughly 


Myofibrosis  (Chronic  Myocarditis).  (Schmaus.)  X  150 
diameters,  m.  Cardiac  muscle-fibers,  b,  b.  Newly  formed 
fibrous  connective  tissue.  This  can  often  be  demonstrated 
to  be  of  different  ages,  and  in  the  older  parts  calcareous 
change  may  have  occurred. 


SENILE   DEGENERATION    OF   THE   STOMACH 


107 


with  gastric  juice.  If  food  has  been  bolted  without  proper 
mastication,  it  may  be  retained  in  the  stomach  for  many  hours 
or  it  may  pass  into  the  duodenum  unchanged. 

While  there  is  a  natural  loss  of  tone  of  muscular  fiber  in  old 
age,  this  atonicity  is  increased  by  overfeeding,  by  ingestion  of 
large  quantities  of  liquids,  by  swallowing  food  in  lumps,  especially 
meats,  and  by  a  constant  state  of  mental  excitement  such  as 
worry,  rage,  etc. 

Symptoms. — The  symptoms  of  atonic  dyspepsia  are,  a 
feeling  of  distress  or  bloating  lasting  for  several  hours  after  a 
meal;  occasionally  heartburn,  cramps,  nausea,  belching  of  gas. 
Hyperacidity,  which  is  common  in  younger  individuals  who  then 
complain  of  acid  eructations,  is  rare  in  the  aged.  There  is 
usually  tympany  all  over  the  stomach  area  and  a  splashing  sound 
can  be  readily  produced  over  an  extensive  area. 

The  most  important  physical  sign  of  atonicity  is  the  presence 
of  food  in  the  stomach  seven  hours  after  ingestion.  This  is 
determined  by  washing  out  the  stomach,  but  the  result  may 
also  be  due  to  hour-glass  contraction,  pyloric  obstruction  or 
pylorospasm.  Pyloric  obstruction  in  the  aged  is  generally 
caused  by  a  growth;  spasm  is  generally  due  to  hyperacidity 
which  is  rare  in  the  aged.  The  hour-glass  contraction  of  the 
stomach  is  the  result  of  a  healed  ulcer  and  contraction  of  the 
scar.  It  is  rare  in  the  aged.  In  pyloric  obstruction  due  to 
growth  the  pylorus  is  palpable  and  peristaltic  movements  may 
be  observed  over  the  stomach  proceeding  from  left  to  right 
toward  the  pylorus.  In  obstruction  due  to  spasm  the  pylorus 
can  be  felt  during  the  spasms  but  not  in  the  intervals.  Pyloric 
hypertrophy  does  not  occur  in  the  aged.  The  differential  diagno- 
sis between  benign  and  malignant  growths  will  be  considered 
under  Gastric  Carcinoma. 

Patients  suffering  from  hour-glass  contraction  following 
ulcer  rarely  reach  old  age.  Weinstein's  test  is  to  give  the  patient 
some  raisins  or  figs.  After  two  hours  the  stomach  is  washed  out 
when  the  seeds  will  be  found.  The  patient  then  walks  around, 
shakes  himself  up,  then  lies  down  so  as  to  shift  the  contents  of 
the  second  chamber  beyond  the  contraction  to  the  anterior 
chamber.  If  the  stomach  is  now  again  washed  out  seeds  will 
be  found  that  had  gone  into  the  second  chamber  and  had  been 
regurgitated  into  the  first  chamber. 


108  PATHOLOGICAL   OLD   AGE 

In  marked  pyloric  stenosis  there  is  always  a  marked  dilata- 
tion. In  senile  atony  there  is  generally  a  slowly  developing 
dilatation. 

Treatment. — Normal  senile  atony  will  give  no  distress  nor 
will  it  have  any  serious  detrimental  effect  if  dietetic  regulations 
suitable  for  the  aged  are  carried  out.  Owing  to  the  normal 
diminution  of  gastric  juice  the  proteid  intake  must  be  reduced, 
or  if  there  is  excessive  waste  of  tissue  and  an  increase  in  pro- 
tein is  necessary,  pepsin  and  hydrochloric  acid  must  be  given 
with  the  meal.  If  the  patient  has  bad  teeth  the  food  should  be 
comminuted.  Food  should  not  be  taken  in  shorter  intervals 
than  five  or  six  hours.  Fat  should  be  excluded  as  far  as  possible 
and  if  given  at  all,  it  should  not  be  used  for  frying  foods.  Butter 
is  the  best  fat  and  may  be  used  with  bread.  Vegetables  can 
be  taken  but  the  greens  should  be  avoided.  Cabbage,  lettuce, 
spinach,  etc.,  have  little  nutritive  value  and  entail  much  work 
upon  the  digestive  system. 

Fruits  raw  or  stewed  are  good  and  spices  and  condiments 
may  be  used.     Of  beverages  alcoholics  are  to  be  avoided. 

If  there  is  extreme  atony,  lavage  once  or  twice  a  week  may 
be  tried;  ordinarily  it  is  not  required.  Medicinal  treatment  is 
seldom  indicated.  Occasional  lapses  from  dietary  rectitude 
must  be  corrected  by  a  brisk  cathartic  or  if  there  is  much 
distress  the  stomach  tube  should  be  used. 

Senile  Dilatation  of   the  Stomach 

Etiology. — This  is  always  due  to  atony  and  waste  of  the 
muscular  fibers  of  the  gastric  wall.  It  occurs  early  in  those 
who  habitually  overload  the  stomach  especially  among  beer 
drinkers,  and  in  those  who  have  an  early  general  arteriosclerosis. 
If  these  causes  do  not  exist  and  the  individual  is  careful  about 
his  food,  the  dilatation  is  slight  and  gives  little  or  no  sign  of  its 
presence. 

Pathology. — The  dilatation  is  usually  moderate  and  involves 
the  whole  organ,  unless  the  person  has  been  an  excessive  eater 
when  the  fundus  is  greatly  dilated.  There  may  be  marked 
gastroptosis.  The  walls  of  the  stomach  are  thin  but  the  pyloric 
orifice  may  be  hypertrophied.  The  mucous  membrane  is  thin 
and  pale  and  the  glands  are  atrophied. 


SENILE   DEGENERATION   OF   THE    STOMACH 


IO9 


Symptoms. — In  mild  cases  there  are  no  symptoms.  Periodic 
vomiting,  which  is  the  most  marked  symptom  of  gastric  dila- 
tation in  maturity,  is  rare  in  senility.  Eructation  of  gas  occurs 
frequently  in  beer  drinkers  and  sometimes  a  small  amount  of 
fluid  is  brought  up  with  the  gas.  Ordinarily  there  is  a  little 
belching  of  gas  an  hour  or  two  after  meals  or  if  food  is  taken 
while  the  stomach  still  contains  undigested  food.  Vomiting 
will  occur  if  there  is  an  excessive  amount  of  food  in  the  stomach, 
and  some  of  it  is  decomposing,  producing  irritating  toxins. 
It  may  also  occur  when  there  is  some  cause  which  would  pro- 
duce vomiting  in  other  cases,  such  as  shock,  hemorrhage,  cere- 
bral anemia  or  an  emetic.  Clapotage  can  generally  be  elicited 
and  gurgling  can  sometimes  be  felt  over  the  pylorus.  Unless 
there  is  extensive  dilatation  the  physical  signs  are  not  marked. 
If  the  stomach  is  distended  with  gas,  its  outline  may  be  made 
out  by  inspection  and  percussion  and  the  fundus  can  be  mapped 
out  whenever  there  is  a  large  amount  of  food  present. 
The  most  accurate  delineation  of  the  stomach  is  obtained  by 
radiography. 

Treatment. — The  most  important  indication  in  the  treat- 
ment of  senile  dilatation  is  the  regulation  of  food.  The  rule 
"little  and  often"  is  irrational  and  will  make  the  condition 
worse.  Owing  to  the  slowed  digestion,  food  should  not  be 
given  in  shorter  intervals  than  five  hours.  Lavage  is  necessary 
only  if  too  much  or  improper  food  has  been  taken.  A  binder 
will  relieve  the  sense  of  weight  following  a  meal  but  the  benefit 
is  psychic  rather  than  physical.  Medication  is  rarely  indi- 
cated except  perhaps  to  increase  the  tonicity  of  the  abdominal 
walls.  In  such  case  strychnine  in  1/60-grain  doses  may  be 
given,  care  being  taken  to  avoid  excessive  stimulation  of  the 
heart.  Gastroptosis  is  sometimes  relieved  by  an  elastic  abdom- 
inal binder.  Surgical  intervention  is  not  required  unless  the 
gastroptosis  is  due  to  adhesions,  bands  or  similar  surgical 
conditions. 

Pyloric  Insufficiency 

Pyloric  insufficiency  is  a  condition  of  the  pylorus  in  which 
the  orifice  is  not  closed  completely  or  with  sufficient  force,  and 
partly  digested  food  dribbles  through.     This,  in  the  aged,  is  due 


IIO  PATHOLOGICAL   OLD    AGE 

partly  to  waste  of  muscular  fiber,  partly  to  lessened  innervation 
and  partly  to  the  weakened  reflexes  by  which  the  pylorus  opens 
and  closes.  These  causes  are  directly  traceable  to  senile  degen- 
eration of  the  muscular  structure  and  of  the  plexus  of  Auerbach 
and  to  the  diminished  quantity  of  hydrochloric  acid,  which  by 
irritating  the  gastric  side  of  the  sphincter  causes  it  to  open,  and 
when  irritating  the  duodenal  side  causes  contraction  and  closing 
of  the  orifice.  The  only  symptom  which  would  indicate  the 
presence  of  pyloric  insufficiency  is  lientery,  the  stools  containing 
particles  of  protein  matter.  (This  might,  however,  occur  if  there 
is  a  deficiency  of  gastric  juice  and  the  diminished  intestinal  secre- 
tions are  not  sufficient  to  convert  the  proteids  when  there  is  a 
normal  quantity  of  carbohydrates  in  the  food.)  This  condition 
is  sometimes  detected  after  death.  Treatment  is  the  same  as 
in  gastric  atonicity. 

SENILE  DEGENERATION  OF  THE  INTESTINES 

Pathology. — The  degenerative  changes  in  the  intestines  in- 
clude atony  and  waste  of  the  muscular  fibers,  thinning  of  the 
walls,  with  atrophy  of  the  glands,  the  folds  are  smoothed  out, 
and  occasionally  there  are  hernial  protrusions  and  diverticulae. 
Feces  collect  in  the  colon  distending  that  portion  of  the  intestines 
and  the  rectum  and  the  wasted  muscular  fibers  cannot  overcome 
this  distention.  The  colon  consequently  becomes  dilated  form- 
ing a  pouch  which  may  be  3  to  4  inches  in  diameter.  There  is 
lessened  peristalsis,  diminished  intestinal  secretion  and  lessened 
reflex  irritability.  As  a  result  of  these  changes  senile  consti- 
pation is  produced. 

Senile  Constipation 

Etiology. — This  is  a  symptom  of  senile  degeneration  of  the 
intestines.  The  following  causes  contribute  to  this  condition: 
(1)  Diminished  peristalsis  due  to  atonicity  of  the  intestinal 
walls;  (2)  diminished  intestinal  secretions  due  to  atrophy  of 
the  intestinal  glands;  (3)  diminished  reflex  irritability  due  to 
lessened  innervation;  (4)  diminished  bile  supply  thereby  in- 
creasing the  tendency  to  thickening  of  intestinal  mucus  and  the 
formation  of  mucomembranes ;  (5)  unsuitable  food;  (6)  causes 
connected  with  gastric  and  duodenal  digestion.  Other  causes 
of   constipation   as   tumors,  adhesions,   hemorrhoids,  viscerop- 


Bramwell's  "withered  apple"  heart.     (Satterthwaite, 
Med.  Record,  May   14,  1910.) 


SENILE   DEGENERATION   OF   THE   INTESTINES  III 

tosis,  habit,  indigestion,  etc.,  do  not  produce  the  condition  here 
described  which  is  simply  a  manifestation  of  senile  degeneration. 

Symptoms. — Senile  constipation  comes  on  slowly,  the  pa- 
tient finding  a  gradually  lessened  desire  for  stool.  If  he  is  accus- 
tomed to  go  to  stool  at  the  same  time  daily,  he  must  make  a 
sensible  effort  to  expel  it  and  at  times  nothing  will  pass  in  spite 
of  all  straining.  The  stools  are  small  and  hard,  dark  and  dry 
if  they  have  been  long  retained,  or  light,  clayey,  if  there  is  an 
abnormal  deficiency  of  bile.  Occasionally  there  is  impaction  of 
the  colon  with  a  canal  through  the  impaction.  When  this  is 
present  the  stools  pass  as  small,  hard  balls.  We  can  have  a 
senile  constipation  with  a  daily  evacuation;  this  seeming  para- 
dox occurs  only  when  the  feces  are  retained  in  the  bowels  be- 
yond the  normal  period.  In  this  condition  the  stools  are  hard, 
dark  and  dry  and  particles  of  food  will  be  found  that  had  been 
ingested  two  or  three  days  before.  In  colonic  or  rectal  impac- 
tion there  is  a  sense  of  weight  or  fulness  in  the  pelvis  and  a 
feeling  or  desire  for  a  stool  which  does  not  pass  upon  straining. 

Treatment. — In  dealing  with  senile  constipation  we  must 
take  into  consideration  the  various  causes.  There  may  be 
simply  a  dyschezia  or  inability  to  expel  the  feces  from  the  colon 
and  rectum.  In  this  condition  enemas  are  required  and  if  the 
lower  gut  is  impacted,  the  hard  feces  must  first  be  softened  by 
a  prolonged  high  enema,  of  warm  water  containing  a  small 
amount  of  bicarbonate  of  soda.  If  this  will  not  remove  the 
mass  it  must  be  scooped  out.  It  is  sometimes  possible  to  in- 
crease the  expelling  force  by  lowering  the  seat  of  the  closet  or 
raising  the  feet  upon  a  foot  stool.  Cool  rectal  douches  are  often 
serviceable  and  in  some  cases  rectal  bougies  containing  ergotin 
and  strychnine  will  increase  the  tonicity  of  the  rectal  walls. 
Astringent  enemata  will  contract  the  rectal  pouch,  thereby 
lessening  the  tendency  to  impaction  but  they  will  not  increase 
the  expulsive  power  of  the  bowel.  If  the  trouble  lies  solely  in 
the  lower  bowel,  cathartics  are  useless.  In  most  cases  the  ato- 
nicity  extends  throughout  the  whole  length  of  the  intestines  and 
then  peristaltic  stimulants  are  required.  The  most  powerful 
of  this  class  of  drugs  is  a  hypodermic  injection  of  Eserin  i/ioo 
gr.  or  aloes  by  mouth  which  increases  peristaltic  activity  from 
the  stomach  to  the  sphincter-ani  and  produces  a  soft  stool. 
The  main  objection  to  aloes  is  its  tendency  to  cause  congestion 


112  PATHOLOGICAL   OLD   AGE 

of  the  lower  bowel  and  to  produce  hemorrhoids.  It  gripes  but 
this  can  be  overcome  by  combining  rhubarb  with  it.  Bella- 
donna which  is  usually  added  to  overcome  the  griping  effect  is 
contraindicated  as  it  lessens  peristalsis.  Other  peristaltic  stimu- 
lants are:  cascara,  senna,  podophyllum,  leptandrin  and  the 
bile  salts.  Rhubarb  produces  large,  soft  stools  and  it  can 
be  taken  for  years  without  causing  habituation.  It  has  a  mild 
peristaltic  effect  and  it  increases  the  activity  of  the  intestinal 
glands. 

Leptandrin  and  podophyllum  gripe  and  are  inferior  to 
senna,  aloes,  and  cascara  unless  a  hepatic  stimulant  is  required 
at  the  same  time.  If  there  is  a  deficiency  of  bile  it  is  better 
to  supply  this  deficiency  by  using  the  bile  salts  instead  of  em- 
ploying other  hepatic  stimulants,  since  the  bile  salts  themselves 
also  increase  hepatic  activity.  Intestinal  peristalsis  is  normally 
induced  by  the  presence  of  indigestible  portions  of  food,  which 
act  as  a  mild  irritant  to  the  bowels,  and  insufficiency  of  such 
matter  lessens  normal  peristalsis.  In  old  age  there  is  a  waste  of 
the  muscle  fibers  which  produce  peristalsis  and  there  is  probably 
a  degeneration  of  nerve  cells  in  the  intestines.  More  powerful 
stimulation  or  irritation  of  the  intestines  is  required  to  increase 
motility  and  this  can  sometimes  be  brought  about  by  increasing 
the  amount  of  food  refuse  and  cellulose.  As  the  ordinary  foods 
containing  much  cellulose  do  not  contain  sufficient  nutritional 
elements  unless  given  in  large  amounts,  a  combination  of  readily 
digestible  concentrated  foods  and  substances  containing  little 
food  matter  and  much  cellulose  is  indicated.  Spinach,  cabbage, 
cauliflower,  turnips,  beets  and  carrots  contain  much  cellulose. 
Rice  and  sago  are  constipating  but  other  farinaceous  foods  may 
be  taken.  Fresh,  tender,  well-done  meats  may  be  taken,  but 
meats  that  have  been  in  cold  storage  should  not  be  used,  and 
this  applies  not  only  to  constipation  but  to  all  senile  conditions. 
Fresh  boiled  fish  can  be  taken  ad  libitum.  Whole  wheat, 
graham  and  brown  bread,  and  toast  are  good.  Milk  con- 
stipates many  persons  but  buttermilk  does  not.  Tea  and 
spirituous  liquors  should  be  avoided.  Pork,  liver,  mut- 
ton, all  smoked  and  preserved  meat  and  fish,  cheese, 
pastry,  sweets,  eggs  and  nuts  are  objectionable.  A  glass  of 
cold  water  at  bedtime  and  a  glass  of  hot  water  containing  a 
pinch  of  salt  or  a  teaspoonful  of  any  of  the  cathartic  salts  will 


SENILE  DEGENERATION  OF   THE   INTESTINES  113 

help  to  flush  the  bowels.  Large  doses  of  salts  should  not  be 
used  as  they  withdraw  water  from  the  organism  which  the  body 
cannot  spare.     Only  in  the  obese  are  the  salines  of  service. 

Mechanical  measures  such  as  manual  massage,  massage  by  a 
mechanical  roller,  coarse  vibration  will  sometimes  relieve  this 
condition.  They  act  either  by  direct  propulsion  of  intestinal 
contents  or  by  producing  a  mild  irritation  and  consequent 
peristalsis. 

Among  the  most  annoying  concomitants  of  senile  constipation 
are  flatulence  and  coliky  pains  which  are  produced  by  the  intes- 
tinal gases.  These  can  be  avoided  by  taking  occasionally  5-grain 
doses  of  charcoal.  As  the  loss  of  tonicity  and  diminished  glandu- 
lar activity  in  old  age  cannot  be  removed  permanently  a  cure 
of  senile  constipation  is  impossible.  Much  can,  however,  be 
done  by  occasional  stimulation  of  intestinal  activity,  by  emptying 
the  colon  and  rectum  by  means  of  enemata  whenever  there  is  a 
feeling  of  fulness,  by  adhering  to  a  fixed  hour  for  stool,  using  a 
low  seat  or  foot  rest  to  secure  a  more  favorable  position  for 
defecation,  and  by  careful  control  of  the  diet. 

Atony  of  the  Sphincter  Ani 

Atony  of  the  anal  sphincter  is  occasionally  found  in  the  aged 
as  part  of  the  general  loss  of  tonicity  of  the  intestines.  The 
patient  finds  that  he  must  make  a  sensible  effort  to  close  the 
sphincter  after  defecation  and  it  requires  an  effort  to  keep  it 
closed  when  there  is  desire  for  stool  at  an  inopportune  time. 
Small  amounts  of  feces  dribble  out  unconsciously  and  his  clothes 
are  constantly  soiled,  and  when  expelling  flatus  from  the  bowels 
he  cannot  control  the  passage  of  feces  at  the  same  time.  If 
internal  hemorrhoids  exist  they  protrude  from  the  anus.  An 
effectual  treatment  of  this  condition  is  the  occasional  inunction 
of  the  sphincter  with  nutgall  ointment  to  which  10  per  cent,  of 
ergotin  is  added.  The  base  should  be  lanoline.  Other  astring- 
ents may  be  used  but  they  may  cause  contraction  of  the  rectal 
walls  and  constipation. 

Anal  Fissure 

Anal  fissure,  while  not  a  degenerative  process,  is  frequently 
found  in  the  aged,  associated  with  atony  of  the  sphincter. 
With  the  waste  and  atony  of  the  muscular  fibers,  atrophy  of 

8 


114  PATHOLOGICAL    OLD    AGE 

mucous  membrane  and  changes  in  the  skin  immediately  surround- 
ing the  anal  orifice,  slight  causes  will  suffice  to  produce  fissures 
in  and  about  the  sphincter.  Hardened  feces  or  the  sudden 
expulsion  of  feces  or  scratching  are  the  most  frequent  causes  of 
this  distressing  lesion.  The  fissures  themselves  are  generally- 
very  small,  even  microscopic,  and  when  visible  appear  like  short 
scratches  about  the  sphincter.  They  may  extend  to  the  sub- 
cutaneous tissue  and  are  then  painful,  otherwise  they  cause  a 
pruritus  which  is  aggravated  by  defecation.  They  do  not  heal 
readily  as  the  passage  of  feces  causes  frequent  irritation  and  the 
intolerable  itching  causes  scratch  lesions  which  may  become 
eczematous  or  infected.  A  2  per  cent,  cocaine  solution  will 
temporarily  relieve  the  itching  and  a  zinc  ointment  with  a  petro- 
latum base  will  prevent  irritation  and  may  effect  a  cure. 

SENILE  DEGENERATION  OF  THE  LIVER 

Senile  degeneration  of  the  liver  is  part  of  the  general  process 
of  involution  and  is  usually  associated  with  and  due  to  arterio- 
sclerosis of  the  hepatic  artery.  Cases  are  occasionally  found, 
however,  in  which  the  liver  is  degenerated  while  the  artery  is 
unimpaired. 

Pathology. — The  senile  liver  resembles  the  liver  in  the  atrophic 
stage  of  cirrhosis.  If  there  is  no  disturbance  of  the  general  circu- 
lation the  organ  is  lighter  in  color  than  in  maturity,  but  as  there 
is  usually  some  impairment  of  the  circulation  causing  passive 
hyperemia  the  color  is  dark  brown  and  dotted  sometimes  with 
yellowish  spots  of  fat  deposits.  The  organ  is  contracted,  the 
acini  are  compressed  through  proliferation  of  the  connective 
tissue  and  the  capsule  is  thick,  opaque  and  closely  adherent  to 
the  body  of  the  gland.  The  suspensory  ligaments  are  weakened 
and  this  with  a  flaccid  diaphragm,  and  with  changes  in  the  chest 
wall  permits  a  ptosis  of  the  organ  with  displacement  to  the  left. 

Symptoms. — The  only  marked  symptom  is  the  intestinal 
disturbance  due  to  diminution  of  bile  secretion,  the  stools  being 
foul-smelling  and  light  in  color.  If  the  bile  is  insufficient  to 
emulsify  the  fat  ingesta,  fat  globules  will  be  found  in  the  feces. 
Percussion  elicits  a  diminution  in  the  size  of  the  organ  and  a 
probable  ptosis  with  lateral  displacement.  It  is  sometimes 
possible  to  feel  the  upper  border  below  the  ribs  while  the  tense 


*yA. 


Pulmonary  fibrosis,  usually  described  as  Chronic  Interstitial 
Pneumonia,  a  condition  frequently  found  in  senile  lungs.  Illustration 
from  Coplin's  "Manual  of  Pathology." 

Bands  of  fibrous  tissue  following  course  of  interlobular  septa  and 
surrounding  blood-vessels  and  bronchi.  (Laud is,  Fifth  Ann.  Rep.  of 
Phipps  Inst.) 


SENILE   DEGENERATION   OF   THE   LIVER  115 

lower  border  can  sometimes  be  felt  below  the  umbilicus.  It  is 
not  tender  upon  pressure  and  it  gives  none  of  the  usual  symptoms 
of  cirrhosis.  If  jaundice  is  present  it  is  invariably  due  to  occlu- 
sion of  the  bile  duct  or  to  some  pathological  state  of  the  gall- 
bladder. 

Treatment. — Treatment  is  rarely  indicated.  The  diminished 
amount  of  food  taken  by  the  aged  requires  a  diminished  amount 
of  bile  and  it  is  only  when  this  diminished  quantity  is  insufficient 
— as  evidenced  by  light-colored  stools — that  anything  need  be 
done  to  stimulate  the  functions  of  the  organ.  By  far  the  best  rem- 
edy in  this  condition  is  inspissated  ox  gall  in  5 -grain  doses  two 
or  three  times  a  day.  This  acts  as  a  hepatic  stimulant,  causes 
a  more  fluid  bile  and  at  the  same  time  supplies  the  deficiency 
of  bile  in  the  intestines.  Other  cholagogues  like  calomel,  sodium 
succinate,  sodium  sulphate,  sodium  salicylate,  benzoic  acid  and 
the  many  vegetable  drugs  may  be  given  but  none  equals  the 
natural  bile  salts. 

SENILE  DEGENERATION  OF  THE  GALL-BLADDER 

Senile  degeneration  of  the  gall-bladder  is  important  on  account 
of  its  interference  with  the  secretion  of  bile  and  on  account  of 
secondary  effects  caused  by  retention  of  bile  and  formation  of 
gall-stones. 

Pathology. — The  walls  of  the  gall-bladder  become  thickened 
and  rigid  through  thickening  of  the  fibrous  coat.  This  also 
diminishes  the  cavity  of  the  gall-bladder  and  a  contraction  of  the 
walls  causes  a  diminution  in  the  size  of  the  organ.  Occasionally 
there  are  lime  deposits  in  the  walls  and  a  layer  of  inspissated 
cholesterin  lining  the  cavity  has  been  reported.  The  neck  is 
contracted,  the  lumen  of  the  cystic  duct  is  diminished  and  in 
rare  cases  it  is  entirely  obliterated.  The  common  duct  is  usually 
dilated. 

The  amount  of  bile  is  diminished  and  it  contains  more  choles- 
terin than  in  maturity,  the  secretion  becomes  jelly-like  and  fre- 
quently hardens,  forming  gall-stones.  These  may  give  rise  to 
cholecystitis  and  the  usual  symptoms  of  gall-stones. 

Symptoms. — Degeneration  of  the  gall-bladder  gives  no 
symptoms  unless  the  gall-stones  increase  in  size  or  number  so  as 
to  cause  local  inflammation,  or  move  toward  the  duodenum 


Il6  PATHOLOGICAL   OLD   AGE 

when  they  may  produce  the  familiar  symptoms  of  cholelithiasis. 
Complete  occlusion  of  the  cystic  duct  may  occur  without 
marked  symptoms,  the  bile  flowing  from  the  liver  through  the 
hepatic  and  common  ducts  to  the  duodenum.  If,  however,  the 
common  duct  is  occluded  there  is  jaundice  and  the  intestinal 
symptoms  of  deficient  bile  secretion  are  produced,  such  as  clayey, 
foul-smelling  stools  containing  fat  globules.  It  is  often  impossi- 
ble to  determine  whether  the  deficiency  of  bile  in  the  intestines 
is  due  to  the  liver,  cyst  or  ducts  as  it  may  be  caused  by  a 
diminished  formation,  a  change  in  the  character  of  the  secretion 
or  an  obstruction  to  the  flow.  If  there  is  obstruction  and  con- 
sequent jaundice,  the  fault  lies  in  the  ducts.  A  change  in 
character  may  arise  in  the  liver  but  is  more  probably  due  to 
prolonged  retention  in  the  gall-bladder.  This  may  give  rise 
to  occasional  colicky  pains  but  the  diagnosis  cannot  be  positively 
made  until  the  symptoms  of  cholecystitis  or  cholelithiasis  appear. 
Treatment. — The  only  medical  treatment  applicable  to 
degeneration  of  the  gall-bladder  has  for  its  purpose  the 
production  of  a  more  fluid  and  a  more  copious  flow  of  bile,  as  has 
been  recommended  under  the  treatment  of  degeneration  of  the 
liver.  This  has  no  effect  upon  the  degeneration  itself,  but  it 
enable  the  organ  to  perform  its  functions  more  readily  and 
prevents  irritation  and  inflammation.  If  cholecystitis  or  chole- 
lithiasis occurs,  surgical  intervention  is  necessary. 

SENILE  DEGENERATION  OF  THE  KIDNEY 

The  senile  contracted  kidney  is  the  physiological  kidney  of  old 
age  and  is  mentioned  here  only  because  pathologists  frequently 
report  the  finding  at  autopsies  of  chronic  interstitial  nephritis 
that  gave  no  symptoms  during  life. 

The  senile  anatomical  changes  have  been  described.  They 
differ  from  the  pathological  changes  found  in  nephritis  in  the 
absence  of  hyaline  and  fatty  degeneration  and  of  cloudy  swelling 
in  the  tufts  and  vessels.  The  epithelium  of  the  tubules  shows 
no  change  and  the  tubules  are  clear  and  free  from  the  granular 
detritus  which  generally  obstructs  the  tubules  in  nephritis. 

Symptoms. — The  only  symptoms  of  senile  contracted  kid- 
ney are  a  trace  of  albumin  in  the  urine  which  may  persist  during 
life  and  a  diminished  secretion  of  urine.     The  specific  gravity 


SENILE   DEGENERATION   OF   THE  BLADDER  117 

of  the  urine  is  normal  or  but  slightly  decreased,  the  urates  are 
considerably  diminished  and  calcium  salts  also  are  generally 
diminished.  The  diminution  of  the  urates  and  calcium  salts 
is,  however,  not  due  to  the  kidney  changes  but  to  metabolic 
changes  and  only  the  diminished  quantity  of  urine  of  normal  or 
slightly  decreased  specific  gravity  and  a  persistent  albuminuria 
without  casts  are  indicative  of  senile  contracted  kidney  (see  Chronic 
Interstitial  Nephritis). 

Treatment. — Nothing  need  be  done  unless  the  amount  of 
urine  is  markedly  diminished  when  drinking  large  quantities 
of  alkaline  mineral  water  will  be  found  effective.  Other  diuret- 
ics are  rarely  required. 


SENILE  DEGENERATION  OF  THE  BLADDER 

Etiology. — While  dilatation  of  the  bladder  through  atony  of 
the  muscular  coat  is  part  of  the  normal  process  of  involution  the 
condition  is  aggravated  through  the  retention  of  urine.  Thus 
one  of  the  many  vicious  circles  of  senility  is  produced.  The 
atonicity  of  the  organs  permits  retention  of  urine  which  further 
distends  the  bladder,  further  stretching  and  weakening  the  mus- 
cular coat,  and  this  in  turn  permits  greater  retention  and  disten- 
tion. A  frequent  cause  of  retention  of  urine  is  a  hyper- 
trophied  prostate  which  obstructs  the  free  passage  of  urine. 
In  some  cases  the  diminished  sensitiveness  and  irritability  of 
the  organ  makes  the  need  for  micturition  less  strongly  felt  and 
the  aged  individual  neglects  it. 

Pathology. — The  pathology  is  an  exaggeration  of  the  normal 
senile  changes.  There  is  atony  and  waste  of  the  longitudinal 
muscular  fibers  and  of  most  of  the  circular  fibers.  Some  of  the 
latter  degenerate  into  fibrous  bands  which  contract,  and  the 
weakened  wall  bulging  out  between  these  contracted  bands 
forms  rugae,  pockets  and  pouches.  The  mucous  membrane 
becomes  atrophied,  the  whole  organ  is  dilated  and  its  contrac- 
tility is  lessened.  In  rare  cases  the  contractions  produced  by 
the  fibrous  bands  may  be  so  numerous  or  extensive  as  to  diminish 
the  capacity  of  the  organ.  There  is  usually  atony  of  the  sphincter 
due  to  waste  of  the  muscular  fibers  and  sometimes  to  pressure 
of  an  enlarged  prostate. 


Il8  PATHOLOGICAL   OLD    AGE 

Symptoms. — The  earliest  symptom  of  degeneration  of  the 
bladder  is  a  diminution  in  the  expulsive  power  of  the  organ. 
The  patient  cannot  send  the  stream  as  far  as  formerly.  Then 
he  finds  that  it  requires  a  sensible  effort  to  void  the  urine,  that 
it  takes  a  few  moments  of  straining  before  the  flow  appears  and 
instead  of  coming  out  with  force,  it  is  sluggish.  Later  the 
stream  is  small  and  drops  from  the  meatus.  After  the  bladder 
has  become  dilated  there  is  retention  of  urine  and  in  addition 
to  the  other  symptoms  there  is  a  frequent  desire  to  urinate, 
especially  at  night,  and  if  there  is  atony  of  the  sphincter  the 
patient  may  wet  the  bed.  There  is  generally  a  sense  of  weight 
in  the  pelvis,  relieved  after  the  bladder  is  emptied.  Dribbling 
is  always  due  to  atony  of  the  sphincter.  Occasionally  there  is 
constant  dribbling,  the  urine  flowing  away  as  soon  as  it  en- 
ters the  bladder  from  the  ureters.  If  there  is  marked  aton- 
icity  of  the  bladder  and  sphincter  there  may  be  retention  and 
incontinence. 

Diagnosis. — The  diagnosis  of  dilatation  of  the  bladder  and 
atony  of  the  sphincter  are  readily  made  but  care  must  be  taken 
to  eliminate  other  factors  which  may  cause  these  symptoms. 
There  may  be  retention  without  atonicity — due  to  stone,  tumor, 
hypertrophied  prostate  or  an  old  stricture.  In  such  case  there 
will  be  difficulty  in  starting  the  flow,  but  after  it  is  started  it 
comes  out  with  force  whether  coming  naturally  or  if  drawn  off 
with  a  catheter. 

If  due  to  stone  the  trouble  is  worse  when  the  patient  is 
much  on  his  feet;  if  due  to  enlarged  prostate  the  difficulty  is 
more  pronounced  at  night  or  in  the  early  morning.  A  positive 
diagnosis  is  made  by  means  of  rectal  examination,  sound  and 
cystoscope.  This  also  applies  to  growths.  Dribbling  or  pass- 
ing a  few  drops  of  urine  after  urination  is  apparently  completed 
is  evidence  of  atony  of  the  sphincter.  If  after  catheterization 
the  patient  is  laid  upon  his  back,  then  turned  upon  his  face  and 
made  to  arise,  the  desire  to  urinate  or  the  presence  of  more 
urine  upon  an  immediate  recatheterization  shows  the  presence 
of  retained  urine  in  the  vesical  pouches.  These  may  be  minute 
and  hold  not  more  than  a  drop  or  two  in  each  pouch  but  when 
these  drops  are  long  retained  they  decompose,  cause  local  irri- 
tation and  inflammation.  A  distended  bladder  can  readily  be 
made  out  by  palpation  and  percussion  and  confirmed  by  the 


Section  of  the  Lung,  Pneumoconiosis.     (Riiidticisc/i.)     The  deposited  pig- 
ment is  shown  in  the  connective  tissue  of  the  vesicular  wall. 


Dilated  stomach.  Combined  dis- 
placement and  dilatation  of  lesser  de- 
gree.    (From  Greene  after  Riegel.) 


SENILE   DEGENERATION    OF   THE  BLADDER  119 

catheter.  Without  this  confirmation  it  may  be  mistaken  for 
ascites.  Occasionally  the  insertion  of  the  catheter  will  excite 
urethral  spasm  which  may  be  mistaken  for  some  other  form  of 
obstruction.  An  injection  of  a  2  per  cent,  solution  of  cocaine 
in  warm  water  will  relieve  spasm  but  not  organic  obstruction. 
The  character  of  the  urine  gives  us  little  information.  A  reten- 
tion urine  is  ammoniacal,  due  to  decomposition,  and  is  turbid. 
If  the  turbidity  is  not  cleared  up  by  heat  it  is  due  to  bacteria; 
but  bacterial  urine  is  frequently  found  in  the  aged  without 
discernible  cause  or  ill  effects.  Pus  and  blood  in  the  urine  may 
be  due  to  vesical  disease  but  they  do  not  occur  in  uncomplicated 
senile  degeneration. 

Treatment. — In  the  treatment  of  senile  bladder  affections 
the  first  indication  is  to  empty  the  bladder  and  secure  an  evacua- 
tion of  it  at  intervals  of  not  more  than  eight  to  twelve  hours. 
The  patient  should  be  impressed  with  the  necessity  of  attend- 
ing to  the  demand  for  evacuation  of  the  bladder  without  delay 
and  if  he  feels  that  he  has  not  passed  all,  he  should  get  on  his 
knees  and  press  the  edge  of  the  vessel  against  the  perineum. 
If  catheterization  becomes  necessary  the  patient  should  be 
taught  how  to  use  it  and  how  to  sterilize  it.  The  sterilization 
must  be  repeatedly  insisted  upon  until  it  becomes  a  habit,  as 
the  aged  become  forgetful  and  careless,  the  few  drops  of  urine 
remaining  in  the  catheter  decompose  and  with  the  next  inser- 
tion bacteria  are  introduced  into  the  bladder.  Internal  medica- 
tion has  two  objects,  the  prevention  of  decomposition  and  the 
increase  of  tonicity.  If  there  are  other  pathological  conditions 
present  these  require  treatment  apart  from  the  treatment  for 
atonicity.  Decomposition  is  prevented  by  the  use  of  hexa- 
methalenetetramin  which  appears  on  the  market  under  various 
trade  names,  urotropin,  formin,  cystogen,  uritone,  etc.  The 
dose  is  5  grains  twice  daily,  always  to  be  given  in  solution.  No 
other  urinary  antiseptic  approaches  this  in  efficacy.  To  in- 
crease the  tonicity  of  the  organ,  strychnine  and  electricity  will 
be  found  beneficial.  Belladonna  which  is  almost  a  specific  in 
incontinence  of  urine  in  childhood  aggravates  the  senile  atony 
of  the  sphincter.  If  there  is  no  arteriosclerosis  ergot  can  be 
given  in  doses  of  15  minims  of  the  fluid  extract  three  times  a 
day.  If  there  is  arteriosclerosis  with  high  blood  pressure  its 
powerful   vasoconstrictor   effect   may   cause   cerebral    trouble. 


120  PATHOLOGICAL    OLD   AGE 

Aloes  has  been  recommended  on  account  of  its  property  to 
stimulate  peristalsis  thereby  increasing  the  activity  of  the 
muscle  fibers.  This  action  is  directed  more  particularly  to  the 
lower  intestinal  tract  and  it  has  little  if  any  effect  upon  the  blad- 
der. The  injection  of  astringents  and  mild  silver  solutions  have 
sometimes  a  temporary  beneficial  effect.  A  single  disten- 
tion will  undo  all  the  good  that  may  have  been  achieved  by 
treatment. 

SENILE  DEGENERATION  OF  MALE  GENITALS 

Senile  Impotence 

The  male  reproductive  organs  undergo  profound  anatomical 
changes,  out  of  all  proportion  to  the  functional  changes  that 
occur  in  old  age. 

Pathology. — The  testes  are  atrophied,  the  fibrous  coat  is 
thickened,  there  is  a  proliferation  of  connective  tissue  through- 
out the  gland,  compressing  the  lobules  and  their  seminiferous 
tubes,  some  of  which  are  completely  obliterated,  while  in  others 
the  lumen  is  compressed  and  occluded.  The  vas  deferens  is 
hardened  and  thickened,  its  caliber  is  diminished  and  the 
seminal  vesicles  are  atrophied.  The  semen  becomes  more  fluid 
and  transparent,  while  in  some  pigment  is  deposited  giving  the 
semen  a  brown  color,  and  the  spermatozoa  are  diminished  in 
number  but  their  functional  activity  is  not  impaired.  Active 
semen  has  been  found  in  the  tenth  decade  of  life. 
v  The  penis  is  shrunken,  the  glans  hardens  and  the  whole 
organ  becomes  less  sensitive.  The  skin  of  the  penis  and  scrotum 
undergoes  the  same  changes  that  occur  in  other  parts  of  the 
body  and  in  addition  the  whole  genital  region  becomes  pig- 
mented and  there  is  often  a  fetid  bromidrosis. 

Functional  Changes. — Diminution  both  in  sexual  desire  and 
power  of  erection  is  generally  noticed  during  the  fifth  or  sixth 
decade  and  these  are  the  principal  manifestations  of  the  male 
critical  period;  in  many  cases,  however,  there  is  apparently 
little  or  no  loss  of  functional  activity.  Where  diminishing  libido 
and  potentia  proceed  together  the  impairment  may  not  be 
noticed,  since  neither  mental  nor  physical  distress  is  produced. 
It  is  only  when  attention  is  called  to  the  lessened  functional 
powers — as  by  marriage  with  an  erotic  woman — that  the  condi- 


SENILE   DEGENERATION   OF   MALE    GENITALS  121 

tion  is  recognized.  In  some  cases  the  desire  remains  after  the 
power  of  erection  has  waned,  a  condition  frequently  found  in 
confirmed  masturbators. 

Treatment. — The  treatment  of  senile  impotence  depends 
upon  the  general  physical  condition  of  the  individual  and  attend- 
ing circumstances.  In  cases  where  there  is  a  gradual  diminu- 
tion in  erectile  power  and  a  diminution  in  desire  nothing  need 
be  done  unless  marriage  is  contemplated.  We  must  bear  in 
mind  that  the  intense  mental  and  physical  exertion  during 
coitus,  and  the  succeeding  depressing  reaction  are  detrimental 
to  the  aged  individual  and  if  there  is  uncompensated  heart 
disease  a  fatal  result  may  ensue.  Where  the  desire  remains 
but  the  power  is  lost  it  is  often  difficult  to  decide  whether 
aphrodisiac  or  anaphrodisiac  measures  shall  be  employed. 
The  object  of  treatment  in  such  cases  is  to  diminish  the  libido 
and  at  the  same  time  slightly  increase  the  potentia  in  order  to 
produce  a  favorable  psychic  effect.  The  patient's  wish  is  to 
have  the  power  of  erection  restored  and  he  will  not  willingly 
follow  any  treatment  which  will  lessen  the  desire.  It  will 
therefore  be  necessary  to  resort  to  anaphrodisiac  drugs  such  as 
bromides,  monobromated  camphor,  valerian  and  lupidin,  and 
at  the  same  time  use  local  stimulants,  warm  applications, 
massage  and  electricity.  The  water  applications  and  massage 
have  only  a  momentary  effect,  still  sufficient  to  satisfy  the 
patient.  As  the  frequency  and  the  intensity  of  the  libido 
diminish  under  above  drug  treatment,  local  stimulation  can  be 
lessened  and  finally  omitted  entirely.  Electrical  stimulation 
by  means  of  the  f  aradic  current  is  more  permanent  but  it  should 
not  be  employed  unless  the  other  measures  fail  or  a  prolonged 
effect  is  desired.  Local  irritation,  as  from  a  hypertrophied 
prostate,  may  keep  up  the  hypererosis.  Lascivious  literature, 
pornographs,  the  goading  and  teasing  of  thoughtless  friends, 
all  tend  to  keep  the  mind  directed  to  the  impaired  function. 
The  removal  of  every  source  and  form  of  erotic  stimulation  is 
necessary  for  success.  If  aphrodisiac  treatment  is  desired,  the 
above-mentioned  local  measures  should  be  employed  and  in 
addition  the  ordinary  aphrodisiac  remedies  may  be  given 
internally.  Ergot  which  is  probably  the  best  drug  for  func- 
tional impotence  cannot  be  used  in  senile  cases  on  account  of 
its  vasoconstrictor  effect.     Phosphorus  or  zinc  phosphide  with 


122  PATHOLOGICAL   OLD   AGE 

nux  vomica  are  reliable  aphrodisiacs  but  the  action  is  not 
permanent  and  constantly  increasing  doses  must  be  given. 
Sandalwood  oil  in  io-minim  doses  three  times  a  day  is  some- 
times effective.  Damiana  and  muirapuama  are  of  little  use  in 
the  aged  while  yohimbin,  recommended  as  an  aphrodisiac,  is 
an  irritant  to  the  genital  organs,  the  irritation  producing  the 
erection.  A  lymph  compound  consisting  of  lymph,  lymphatic 
gland  extract,  brain  and  cord  extracts  from  goats  and  orchitic 
fluid  from  bulls  has  been  reported  effective  in  some  cases. 

Psychic  measures  usually  give  immediate  and  often  lasting 
results,  marriage  with  a  young  person  being  sometimes  fol- 
lowed by  happy  results  without  other  treatment.  Association 
with  young  persons,  flattery  by  a  person  of  the  opposite  sex, 
sensuous  pleasures,  all  tend  to  bring  about  the  desired  effect. 

Senile  satyriasis,  inordinate  erotic  desire,  occurs  occasionally 
in  the  aged.  The  bromides  in  large  doses  will  cure  this  condi- 
tion. If  occurring  as  a  recrudescence  after  years  of  quiescence, 
it  is  a  symptom  of  senile  dementia.  It  then  usually  appears 
during  the  senile  climacteric  and  may  lead  to  acts  of  violence. 
Bromides  and  narcotics  are  required.     Threats  are  useless. 

SENILE  DEGENERATION  OF  THE  PROSTATE 

The  senile  changes  in  the  prostate  are  hypertrophy  and 
atrophy  of  the  gland.  Hypertrophy,  which  is  found  in  about 
one-third  of  all  cases,  is  an  anomaly  in  senile  involution  as  it  is 
the  only  case  presenting  an  increase  of  glandular  tissue  as  a 
senile  change.  Many  theories  have  been  advanced  for  this 
peculiarity;  none  is  satisfactory.  A  rational  explanation  may 
be  found  in  the  theory  of  tissue-cell  evolution  advanced  in  this 
work. 

Pathology. — The  hypertrophy  assumes  various  forms.  Some- 
times the  whole  gland  is  enlarged,  occasionally  it  is  limited 
to  one  or  both  lateral  lobes,  more  often  the  middle  lobe  is 
larger  than  the  others.  In  most  cases  the  hypertrophy  con- 
sists of  glandular,  muscular  and  fibrous  elements,  the  latter 
two  predominating.  Occasionally  the  glandular  element  is 
greater,  producing  a  soft  hypertrophy.  The  mass  is  generally 
unsymmetrical,  may  reach  the  size  of  a  hen's  egg  and  con- 
tains numerous  small  fibrous  tumors,  which  in  connection  with 


Fissure  in  ano.      (From  Gant's  "Constipation.") 


SENILE   DEGENERATION   OF   THE   PROSTATE 


123 


prostatic  concretions  frequently  block  up  the  ducts.  If  the 
hypertrophy  is  lateral  it  twists  the  prostatic  portion  of  the 
urethra  and  if  central  it  flattens  and  compresses  the  canal. 

Symptoms. — While  cases  have  been  recorded  in  which  pros- 
tatic hypertrophies  have  been  found  which  gave  no  symptoms 
during  life  this  condition  usually  gives  early  evidence  of  its 
presence.  The  old  man  finds  that  he  must  urinate  more  fre- 
quently, especially  at  night,  that  he  must  make  a  sensible  effort 
to  start  the  flow  and  that  it  comes  in  a  small  stream  without 
any  force  behind  it.  Later  on,  there  is  a  feeling  of  uneasiness 
or  of  dissatisfaction  as  if  he  had  not  been  able  to  completely 
empty  the  bladder  and  he  wants  to  pass  a  little  more.  There 
is  always  an  amount  of  residual  urine  in  the  bladder  which 
decomposes  and  may  produce  cystitis.  After  a  time  there  is 
retention  of  urine  with  dilatation  of  the  bladder,  still  later  the 
atony  of  the  sphincter  induced  by  the  senile  waste  of  the  muscle 
fibers  or  by  paralysis  caused  by  pressure,  permits  dribbling  and 
we  have  retention  with  incontinence.  There  is  now  atony  and 
dilatation  of  the  badder  with  retention  of  decomposing  urine, 
atony  or  paralysis  of  the  sphincter,  the  lumen  of  the  upper  part 
of  the  urethra  being  diminished  and  perhaps  twisted,  and 
owing  to  the  size  of  the  gland  it  is  forced  upward  carrying  the 
neck  of  the  bladder  with  it.  Urination  is  now  impossible  with- 
out the  catheter  and  catheterization  must  be  performed  two 
or  three  times  a  day.  A  frequent  complication  is  septic  bac- 
terial infection  produced  by  the  catheter.  Urosepsis  from  this 
source  leads  to  a  train  of  septic  inflammations  beginning  with 
urethritis  and  cystitis  and  involving  allied  organs  and  tissues 
until  pyelitis  and  exhaustion  terminate  life.  The  diagnosis  of 
prostatic  hypertrophy  may  be  made  by  rectal  examination 
in  the  knee-chest  position.  The  only  conditions  which  present  a 
growth  or  tumor  in  the  locality  of  the  prostate  are  cancer  and 
stone.  Cancer  gives  the  symptoms  of  cachexia,  hematuria  and 
pain.  Calculus  is  movable  and  its  diagnosis  can  be  confirmed 
by  the  searcher  and  cystoscope. 

Treatment. — The  excellent  results  achieved  in  recent  years 
by  partial  and  total  prostatectomy  and  the  unsatisfactory 
results  of  medical  treatment  have  removed  prostatic  hyper- 
trophy from  the  field  of  the  physician  to  that  of  the  surgeon. 
Shall  it  be  a  complete  or  a  partial  removal  of  the  mass,  shall  it 


124  PATHOLOGICAL   OLD   AGE 

be  extirpation  or  enucleation,  suprapubic  or  perineal,  shall  it  be 
performed  early  or  late  ?  Each  has  its  advocates  and  opponents 
and  each  has  been  successful.  Every  surgeon  has  his  favorite 
method  of  operation  and  judging  from  results  there  is  little  to 
choose  between  them.  Perineal  enucleation  seems  to  have  a 
lower  mortality  but  more  frequent  unfavorable  after-effects, 
such  as  fistulae,  strictures,  incontinence,  etc.  As  for  the  time 
when  the  operation  shall  be  performed  some  advise  it  before 
the  catheterization  habit  has  been  formed,  others  favor  it  when 
the  catheter  fails  to  remove  the  residual  urine,  others  again  will 
not  operate  except  as  a  last  resort.  Bottini's  galvano-cautery 
operation  has  not  given  the  favorable  results  in  the  hands  of 
his  followers  that  he  has  reported  in  his  own  cases.  Local 
applications,  formerly  much  in  vogue,  have  fallen  into  disuse. 
The  only  drugs  from  which  any  improvement  has  been  reported 
are  iodine,  silver  and  mercury,  yet  real  benefit  from  either  has 
been  rarely  recorded.  Straightening  and  stretching  the  ure- 
thral canal  by  means  of  sounds  has  relieved  the  dysuria  but  has 
no  effect  upon  the  prostate.  If  catheterization  becomes  neces- 
sary the  old  man  should  be  taught  how  to  use  the  catheter  and 
how  to  sterilize  it.  He  generally  becomes  more  expert  in  the 
introduction  than  the  physician  himself,  but  there  is  some 
danger  that  in  his  hands  it  will  lead  to  sexual  perversions.  The 
family  should  look  after  the  sterilization  of  the  instrument  and 
this  should  be  performed  immediately  before  and  after  its  use. 
Atrophy  of  the  prostate  is  the  form  of  degeneration  that  is 
analogous  to  the  senile  degeneration  in  other  glandular  organs. 
It  occurs  in  about  10  per  cent,  of  the  cases.  It  is  only  of  im- 
portance when  the  proliferated  fibrous  bands  constrict  the 
prostatic  portion  of  the  urethra  and  interfere  with  the  free  flow 
of  urine.  In  that  case  sounds  should  be  used  to  dilate  that 
portion  of  the  canal  while  the  catheter  is  used  to  draw  off  the 
urine.  In  extreme  cases  surgical  measures  must  be  resorted  to 
to  relieve  the  ischuria. 

SENILE  DEGENERATION  OF  THE  FEMALE  GENITAL 

ORGANS 

The  senile  degeneration  of  the  female  genital  organs  gener- 
ally occurs  during  the  middle  or  close  of  the  fifth  decade.  The 
anatomical  and  physiological  changes  are  well  marked,  proceed 


SENILE   DEGENERATION   OF   THE   FEMALE    GENITAL   ORGANS     1 25 

rapidly  and  are  accompanied  by  constitutional  symptoms  and 
often  by  pronounced  changes  in  the  entire  organism.  The 
external  genitals  atrophy,  the  labia  are  shrunken,  flabby  and 
do  not  completely  close  the  vulvar  aperture  leaving  the  vaginal 
orifice  exposed.  The  skin  is  dark,  wrinkled  and  leathery;  the 
hair  thin  and  gray.  The  vagina  is  wrinkled,  dry,  easily  dilated 
and  owing  to  the  loss  of  tonicity  of  its  walls,  the  latter  fall 
together.  Occasionally  the  vagina  shrinks,  its  caliber  is  dimin- 
ished and  there  is  a  progressive  atresia.  The  uterus  undergoes 
atrophy  with  marked  histological  changes.  The  atrophy  pro- 
ceeds rapidly  during  the  period  of  the  menopause  then  con- 
tinues slowly  during  the  rest  of  life,  finally  falling  below  the 
weight  and  size  of  the  uterus  at  puberty.  The  walls  contract, 
diminishing  and  occasionally  obliterating  the  cavity.  The  cer- 
vix becomes  elongated.  In  some  cases  annular  or  partial  con- 
strictions of  the  walls  of  the  cervix  and  body  cause  a  series  of 
dilatations  or  completely  enclosed  cavities.  The  mucous  mem- 
brane is  smooth,  but  occasionally  it  is  covered  with  minute 
nodules,  the  remnants  of  glands.  The  external  coat  of  the 
uterus  is  usually  tough,  leathery  and  wrinkled.  The  muscular 
coats  atrophy,  there  is  a  hyperplasia  of  fibrous  connective 
tissue  and  the  elastic  fibers  gradually  disappear.  The  blood- 
vessels degenerate  and  may  become  obliterated.  The  Fallopian 
tubes  become  obliterated  and  appear  as  strings  on  the  border 
of  the  broad  ligaments.  The  ovaries  atrophy,  become  hard, 
dense,  sometimes  containing  calcareous  deposits,  rarely  cal- 
careous incrustations.  The  ovaries  shrivel  and  have  a  rough 
knobbed  appearance  after  the  menopause  but  late  in  life  they 
become  smooth  and  flattened.  The  histological  changes  are 
similar  to  the  changes  in  other  solid  organs,  a  waste  of  muscle 
and  elastic  tissue  and  a  hyperplasia  of  connective  tissue.  The 
Grafnan  follicles  degenerate  into  minute  nodules  or  disappear 
leaving  cavities. 

The  essential  physiological  change  is  the  cessation  of  men- 
struation. Incidental  thereto  is  atrophy  of  the  mammary 
glands  with  the  disappearance  of  milk  and  followed  generally 
by  neuroses  and  sometimes  psychoses. 

While  the  menopause  and  the  discomforts  incident  thereto 
are  physiological,  the  latter  may  be  so  pronounced  as  to  require 
medical  intervention. 


I26  PATHOLOGICAL   OLD   AGE 

The  menses  may  cease  suddenly  or  they  may  appear  at 
irregular  intervals  before  their  final  disappearance.  Nothing 
can  or  need  be  done  to  bring  them  on  although  women  fearing 
that  delayed  menstruation  means  pregnancy,  will  often  insist 
upon  doing  something  to  cause  their  reappearance.  A  persist- 
ent sanguineous  discharge  between  the  menstrual  periods  is 
indicative  of  a  grave  uterine  disorder,  frequently  a  malignant 
growth.  It  may  be  due  to  inflammation  or  traumatism  pro- 
duced by  instruments  used  to  produce  abortion. 

The  uncomfortable  sensations,  flushing  of  the  face,  a  feeling 
of  heaviness  or  uneasiness,  occasional  disinclination  for  work 
and  at  other  times  excessive  activity,  irritability,  etc.,  that 
accompany  the  menopause  can  often  be  relieved  by  the  use  of 
dried  corpora  lutea  given  in  io-grain  doses  several  times  a  day. 
This  should  be  discontinued  as  soon  as  its  therapeutic  effect  is 
produced  and  resumed  when  the  disagreeable  sensations  return. 
The  flushes  and  headache  can  be  speedily  relieved  by  a  hot  foot 
bath.  An  intolerable  vulvar  pruritus  is  sometimes  present  and 
can  be  temporarily  relieved  by  a  2  per  cent,  cocaine  solution  or 

ointment. 

The  neuroses  and  psychoses  that  accompany  the  menopause 
are  often  intractable  but  they  usually  disappear  at  the  comple- 
tion of  the  period.     Irritability  with  occasional  violent,  uncon- 
trollable outbursts  of  temper,  and  hysteria  may  occur.     These 
are  best  treated  by  bromides  and  chloral.      Hyoscine   given 
hypodermically  in   1/100-grain   doses  will  generally  quiet  the 
patient  during  the  violent  attack.     In  many  cases,  however, 
the  outburst  of  temper  lasts  but  a  few  moments  and  is  followed 
by  hysterical  tears  or  by  a  sound  sleep  and  no  treatment  is 
required.     Women  sometimes  know  when  these  attacks  will 
come  on,  they  know  or  feel  that  they  will  have  a  bad  day  and 
while  some  will  try  to  fight  off  the  approaching  feeling  of  irrita- 
bility, others  give  vent  to  their  feelings  and  refuse  every  effort 
to  relieve  themiJThe  treatment  of  these  cases  depends  to  a 
great  extent  upon  the  temperament  of  the  individual  and  psychic 
measures  are  often  more  effective  than  drugs.     The  menopause 
usually   produces   a  profound  psychic   depression  in  childless 
women.     Moral  suasion  is  occasionally  effective  in  these  cases 
but  drugs  are  useless  except  to  produce  a  momentary  stimulation. 
Atresia  of  the  senile  vagina  seldom  produces  much  discomfort 


Senile    Contracted    Kidney.     (Pic   and 
Bonnamour.) 


Senile  Bladder  showing  also  hypertrophied  prostate.     (Pic  and 

Bonnamour.) 


SENILE   DEGENERATION   OF   THE   DUCTLESS    GLANDS  1 27 

and  this  condition  may  pass  unnoticed  unless  discovered  acci- 
dentally. There  may  be  a  local  or  annular  constriction,  more 
often  the  diameter  of  the  canal  is  diminished  throughout  its 
length.  In  a  few  cases  the  constriction  is  sufficient  to  interfere 
with  the  free  discharge  of  the  uterine  and  vaginal  secretions, 
and  in  rare  cases  the  occlusion  is  complete,  preventing  the  dis- 
charge entirely.  There  is  very  little  secretion  from  these  parts 
in  the  aged,  virtually  none  when  the  woman  is  in  the  recumbent 
position.  When  walking  a  slight  mucous  discharge  appears. 
The  retention  of  this  discharge  will  produce  a  catarrhal  vaginitis 
and  may  cause  a  metritis;  occasionally  it  becomes  mucopurulent 
and  may  then  lead  to  local  septic  infection.  The  treatment 
depends  upon  the  extent  of  the  atresia.  Omitting  the  atresias 
due  to  cicatrical  tissue  and  other  surgical  growths,  conditions 
which  are  not  considered  here,  atresia  of  the  vagina  in  the  aged 
seldom  requires  treatment.  In  some  cases  astringent  injections 
will  serve  to  diminish  the  discharge  and  it  is  often  possible  to 
dilate  the  canal  with  the  finger.  For  localized  constriction  a 
tampon  with  boroglyceride  will  usually  be  effectual.  In  the 
rare  cases  of  complete  occlusion  surgical  intervention  is  necessary. 

SENILE  DEGENERATION  OF  THE  DUCTLESS  GLANDS 

Neither  the  anatomical  nor  the  physiological  senile  changes 
in  these  glands  are  well  understood.  While  they  generally 
undergo  atrophy,  hypertrophy  is  occasionally  found,  yet  there 
does  not  seem  to  be  any  marked  perversion  of  function  in  either 
case.  Pic  says,  the  senile  changes  explain  the  lessened  resistance 
to  infection  and  intoxication,  yet  the  aged  have  apparently 
increased  resistance  to  many  forms  of  infection  since  infectious 
diseases  except  erysipelas  are  relatively  less  frequent  in  them 
and  when  they  do  occur  they  are  usually  milder,  and  autoin- 
toxications are  also  borne  better.  Lorand  ascribes  the  senile 
changes  mainly  to  atrophy  of  the  thyroid  gland  yet  thyroid  medi- 
cation will  not  retard  the  changes.  From  our  limited  knowledge 
of  the  internal  secretions  and  their  intimate  interrelations,  increas- 
ing or  diminishing  the  work  of  each  other,  it  is  probable  that  so 
long  as  they  maintain  their  functional  relations  to  each  other  the 
harmonious  relations  of  the  whole  organism  are  maintained. 
This  of  course  presupposes  that  other  organs  are  not  impaired. 


128  PATHOLOGICAL   OLD   AGE 

Atrophy  of  the  ductless  glands  lessens  their  secretions  and  conse- 
quently their  functional  activity  but  counteracting  influences,  as 
the  vasomotor  action  of  the  suprarenals  and  thyroid,  prevent  a 
disturbance  in  their  action.  In  some  cases  excessive  atrophy 
in  one  gland  is  compensated  by  increased  activity  in  others  as 
may  occur  when  the  spleen  is  greatly  atrophied  and  the  lym- 
phatic glands  become  enlarged.  Lacking,  however,  more  definte 
knowledge  of  the  functions  of  the  ductless  glands  and  especially 
of  their  functions  when  they  have  undergone  senile  degenera- 
tion, work  in  this  direction  must  be  based  upon  hypothetical 
assumptions  and  animal  experimentation  which  leave  a  wide 
margin  for  faulty  conclusions. 

Spleen. — The  spleen  is  generally  atrophied,  and  its  weight 
is  greatly  reduced,  weighing  as  little  as  40  grams  instead  of  100 
to  150  grams,  the  normal  weight  in  maturity.  The  Malpighian 
corpuscles  are  correspondingly  atrophied,  the  fibrous  tissue  is 
increased  and  the  walls  of  the  arterioles  are  considerably  thick- 
ened, while  the  arterioles  themselves  may  be  completely  obliter- 
ated through  pressure  or  constriction  produced  by  fibrous  bands. 
The  color  ranges  from  bright  red  to  red  brown.  The  capsule 
is  closely  adherent,  thick,  rough,  opaque,  the  organ  presenting 
the  appearance  of  a  withered  apple.  In  some  cases  the  spleen 
is  found  hypertrophied  but  in  these  cases  there  can  usually  be 
obtained  the  history  of  a  disease  with  which  splenic  hypertrophy 
is  associated. 

In  cases  of  extreme  atrophy  the  spleen  consists  of  a  mass  of 
fibrous  trabeculi  in  which  particles  of  spleen  substance  are  en- 
trapped, and  in  which  most  of  the  blood-vessels  are  obliterated. 
Notwithstanding  these  profound  changes  there  is  apparently 
no  change  in  the  functions  of  the  organ.  It  may  be,  however, 
that  there  is  a  compensating  increase  in  the  functions  of  the 
lymphatic  glands,  as  total  extirpation  of  the  spleen  in  maturity 
is  followed  by  hypertrophy  of  the  lymphatic  glands.  The 
lymphatics  are,  however,  usually  atrophied  in  the  aged.  It  is 
impossible  to  harmonize  the  generally  accepted  views  concerning 
the  functions  of  the  spleen  and  lymphatics  with  the  conditions 
that  exist  in  the  aged.  The  number  and  proportion  of  leuco- 
cytes are  not  diminished,  nor  is  the  character  of  the  blood  ma- 
terially altered.  Malaria  in  the  aged  follows  a  milder  course 
than  in  maturity  and  the  plasmodium  which  is  believed  to  be 


SENILE   DEGENERATION   OF   THE   DUCTLESS   GLANDS  1 29 

destroyed  in  the  spleen,  disappears  under  treatment  as  rapidly  as 
in  maturity,  though  the  spleen  be  extremely  atrophied. 

No  pathological  condition  and  no  disease  symptoms  can  be 
traced  to  senile  degeneration  of  the  spleen. 

Thyroid  Gland. — The  thyroid  gland  is  atrophied  in  the  aged. 
There  is  a  hyperplasia  of  the  fibrous  structure  which  compresses 
the  alveoli,  causing  them  to  atrophy,  thereby  making  the  whole 
organ  denser.  These  changes  proceed  very  slowly  and  the 
organ  is  normally  active  to  a  very  old  age.  There  is  a  vast 
difference  of  opinion  respecting  the  physiological  functions  of 
the  thyroid  in  the  aged.  While  Pelliet  declares  that  the  thy- 
roid is  one  of  the  organs  which  retains  its  physiological  activity 
longest  in  senility,  Leopold  Levi  and  Lorand  ascribe  to  it 
many  or  most  of  the  senile  changes.  Indeed  Lorand  expresses 
the  belief  that  old  age  can  be  deferred  by  preventing  senile 
atrophy  of  the  thyroid  or  by  replacing  the  waste  of  the  organ. 

According  to  Horsley,  the  senile  cachexia  presents  a  remark- 
able resemblance  to  myxedema,  which  is  due  to  a  deficiency  of 
thyroid  secretion,  while  those  aged  persons  who  do  not  present 
this  cachexia  have  active,  healthy  thyroid  glands. 

While  the  thyroid  gland  has  a  profound  influence  upon  nu- 
trition and  a  diminution  of  its  secretion  is  the  cause  of  cretinism 
and  myxedema,  it  is  extremely  doubtful  whether  any  of  the 
normal  senile  changes  are  dependent  upon  the  state  of  that 
organ.  Some  of  the  changes  noted  in  myxedema  are  seen  in 
senility  but  these  are  probably  incidental  to  similar  degenerative 
results,  not  causes. 

Edmunds  found  that  if  calcium  was  administered  to  animals 
in  whom  the  thyroid  and  parathyroid  were  excised,  the  usual 
rapid  death  following  complete  thyroidectomy  was  prevented. 
As  there  is  an  increased  proportion  of  lime  salts  in  senility,  this 
may  explain  why  functional  activity  is  but  slightly  disturbed 
in  senile  atrophy  of  the  gland.  Our  knowledge  of  the  functions 
of  the  gland  is  still  imperfect  and  no  definite  statements  can  be 
made  as  to  the  character  of  the  functional  changes  in  the  aged. 

Suprarenal  Glands. — The  suprarenal  gland  is  generally  atro- 
phied ;  Salrazes  and  Hushot  who  examined  this  organ  in  a  num- 
ber of  aged  persons,  found  it,  however,  often  hypertrophied. 
There  are  two  antagonistic  senile  processes,  a  sclerosis  of  the 
vessels  and  an  increase  in  glandular  tissue,  due  to  fat  deposits 
9 


130  PATHOLOGICAL   OLD   AGE 

in  the  cells  of  the  cortical  layer.  In  the  lower  reticulated  layer  the 
cells  are  surcharged  with  pigment.  Contradictory  views  are 
held  concerning  the  functional  changes  of  the  suprarenals,  some 
authorities  believing  that  there  is  a  hypersecretion  producing  or 
aiding  in  the  production  of  atheroma,  high  blood  pressure, 
pancreatic  degeneration,  abnormal  pigment  deposits,  etc.,  others 
denying  that  the  senile  organs  play  any  such  role  in  the  senile 
processes.  Since  it  is  uncertain  just  what  role  the  senile  supra- 
renal glands  play  in  the  organism,  we  cannot  say  what  per- 
version of  function  or  what  symptoms  are  produced. 

SENILE  DEGENERATION  OF  THE  SKIN 

The  senile  changes  in  the  skin  have  been  described  in  the 
chapter  on  Anatomical  Changes  in  Old  Age.  It  is,  however, 
sometimes  impossible  to  say  whether  some  of  these  changes  are 
physiological  or  pathological,  due  to  the  process  of  involution, 
to  malnutrition  following  arteriosclerosis,  to  dyscrasias,  to  local 
lesions,  or  are  natural  and  normal  conditions  under  certain 
circumstances  not  connected  with  age.  Shall  we  say  the  weather- 
beaten  skin  of  the  sailor  is  pathological  because  it  is  dryer, 
coarser,  rougher,  more  wrinkled  and  more  pigmented  than  the 
skin  of  the  city  dweller,  or  is  it  a  senile  condition  because  the 
senile  exposed  skin  gradually  assumes  the  same  characteristic,  or 
is  it  a  normal  condition  of  maturity  ?  The  skin  of  the  aged  is  dry 
and  it  is  generally  possible  to  rub  off  fine  white  scales  of  dried 
epithelium.  Is  this  pityriasis  tabescentium  a  disease  ?  Some  of 
of  the  manifestations  of  senile  changes  like  pruritus,  pigmentation, 
etc.,  are  distressing  or  annoying,  while  some  like  bromidrosis  may 
exist  through  life,  obvious  to  everyone  except  to  the  individual 
himself. 

There  are  various  perversions  of  the  normal  senile  changes 
in  the  skin,  some  occurring  locally,  others  being  scattered  all 
over  the  body.  The  latter  are  really  dyscrasias  or  due  to 
changes  in  the  blood  vessels.  (These  will  be  taken  up  in  the 
second  group.)  Owing  to  the  changes  in  the  skin  almost  all 
dermatoses  occurring  in  the  aged  are  modified,  some  presenting 
marked  differences  between  those  of  maturity  and  those  of 
senility. 

Some  of  the  manifestations  of  the  senile  changes  in  the  skin 


SENILE   DEGENERATION    OF   THE    SKIN  131 

are  annoying  on  account  of  their  appearance.  Such  are  folds 
and  wrinkles,  pigment  deposits,  the  changes  in  the  hair,  etc. 
The  aged  are  often  more  concerned  about  these  than  about  the 
more  important  pathological  conditions  and  these  are  generally 
the  most  difficult  to  treat.  Pruritus  though  usually  included 
among  the  diseases  of  the  skin  is  dealt  with  under  the  degenera- 
tion of  the  nerves  as  it  is  probably  a  symptom  of  degeneration 
of  the  nerve  terminals. 

Wrinkles  are  usually  the  earliest  of  the  senile  changes  and 
are  due  to  waste  of  muscular  fibers  leaving  layers  of  fat.  It  is 
impossible  to  replace  these  fibers  and  if  the  fat  also  wastes  the 
skin  hangs  in  folds.  Massage  will  improve  the  surface  circula- 
tion and  stimulate  the  remaining  muscular  fibers;  it  might, 
however,  cause  absorption  of  the  fat  and  leave  the  skin  in  folds. 
This  can  be  avoided  by  inunction  with  an  animal  fat,  either 
cream,  sweet  butter,  lard  or  lanoline,  and  mild  massage.  The 
skin  should  be  massaged  across  the  wrinkles,  not  along  the 
wrinkles. 

Florida  water,  glycerin,  bay  rum  and  washes,  ointments, 
and  other  toilet  preparations  containing  alcohol  or  other  desic- 
cants,  are  harmful. 

Pigment  deposits  upon  the  face,  neck  or  hands  are  unsightly  but 
there  is  no  safe  and  certain  method  of  removing  them.  There 
are  usually  extensive  areas  of  pigmentation  about  the  genitals 
and  inner  surface  of  the  thighs,  sometimes  upon  the  chest  and 
frequently  upon  the  back  and  arms.  Pigment  deposits  on  the 
face,  neck  and  hand  are  generally  in  patches  and  spots. 
The  usual  treatment  for  chloasma  patches  and  freckles  applica- 
ble in  younger  persons  will  not  avail  in  senility  as  the  drugs 
employed  are  either  irritants  or  deoxidizing  bleaches  which  act 
as  irritants,  and  owing  to  poor  surface  circulation  the  injury 
done  to  the  skin  by  them  is  not  readily  repaired.  Even  slight 
surface  irritation  is  liable  to  cause  an  ulcer  or  gangrene. 

The  senile  skin  requires  special  care  to  avoid  irritation  and 
to  render  it  presentable.  Soaps  containing  large  amounts  of 
alkali  or  glycerine  are  injurious,  likewise  lotions  and  applica- 
tions containing  alcohol.  Inunction  with  animal  fats  is  benefical 
but  mineral  fat  is  worthless  and  may  be  injurious  as  it  is  not 
absorbed  and  blocks  the  pores.  Face  powders  and  talcum  are 
positively  injurious. 


132  PATHOLOGICAL   OLD    AGE 

Senile  Alopecia 

Alopecia  or  baldness  is  a  symptom,  not  a  disease,  although 
the  pathological  condition  to  which  it  is  due  is  not  always  evi- 
dent .  There  is  a  primary  or  idiopathic  form  including  congenital, 
premature  and  senile  alopecia  and  a  secondary  form  due  either 
to  a  local  disease  as  seborrhea  or  to  a  general  cause  as  syphilis. 
Senile  alopecia  may  appear  in  the  fifth  decade  but  is  usually 
first  noticed  about  the  end  of  the  sixth  decade  and  where  there 
has  been  little  falling  out  of  the  hair  before  the  senile  climac- 
teric it  falls  out  rapidly  during  or  immediatly  following  this  time. 
Pathology. — The  corium  which  forms  the  walls  of  the 
hair  follicles  atrophies  and  the  mouth  of  the  follicle  becomes 
filled  with  epidermal  debris.  The  sebaceous  glands  atrophy  and 
the  hair  consequently  becomes  ill-nourished  and  dry.  While 
the  follicular  walls  can  still  hold  the  roots  in  place  the  dry  hair 
becomes  thin  and  breaks  at  the  point  of  exit  from  the  skin. 
When  the  follicular  walls  become  so  changed  that  they  cannot 
hold  the  roots  the  hairs  fall  out  on  brushing  or  combing. 

Symptoms. — In  senile  alopecia  the  hair  about  the  central 
point  of  the  scalp  back  of  the  crown  becomes  thin  and  the  hairs 
break  off  at  the  point  of  exit  from  the  scalp.  The  breaking  of 
the  hair  later  occurs  all  over  the  scalp,  not  in  patches  as  in  alopecia 
areata,  but  isolated  hairs  break  everywhere.  Owing  to  the 
atrophy  of  the  corium  the  roots  become  loose,  fine  dust  and 
epithelial  debris  work  their  way  under  the  roots  and  push  them 
up  and  brushing  or  combing  dislodges  them.  The  hair  falls  out 
first  about  the  center  of  the  scalp,  the  denuded  surface  gradually 
extending  forward,  and  slowly  backward,  a  thin  border  of  hair 
being  left  at  the  sides  and  back.  In  some  cases  the  hair  first 
breaks  over  the  temples  then  the  rest  of  the  scalp  is  involved. 

Treatment. — The  treatment  of  senile  alopecia  has  been  un- 
satisfactory because  the  measures  employed  were  based  upon 
unscientific  empiricism.  Baldness  is  the  end  result  of  many  dif- 
ferent conditions  and  the  treatment  must  consider  the  primary  or 
causative  condition.  Neglect  to  discover  this  underlying  cause 
is  responsible  for  the  general  failure  of  any  certain  line  of  treat- 
ment which  had  been  successful  in  a  few  cases. 

When  the  hair  falls  out  during  a  fever  it  will  grow  again  with- 
out any  treatment.     If  due  to  parasitic  sycosis,  treatment  insti- 


Progressive  stages  in  Prostatic  Hypertrophy;  Semidiagrammatic.     (Squier,  Medit  al 

Record,  Feb.  3,   1912.) 


SENILE   DEGENERATION   OF   THE    SKIN 


*33 


tuted  before  the  follicles  and  roots  are  destroyed  will  save  the 
roots  and  the  hair  will  grow ;  if  the  follicles  or  roots  are  destroyed 
nothing  will  avail.  In  seborrheic  dermatitis  after  the  dandruff 
is  cured,  the  growth  of  hair  can  be  stimulated  providing  the 
roots  and  follicles  are  not  destroyed.  In  senile  alopecia  the 
success  of  treatment  depends  upon  the  condition  of  the  skin, 
follicles,  roots  and  sebaceous  glands.  The  sebaceous  glands 
are  generally  atrophied  but  the  diminished  sebum  can  be 
replaced  by  an  animal  oil  or  fat.  Petrolatum  is  not  an  animal 
fat  and  its  employment  is  harmful.  The  mouths  of  the  fol- 
licles should  be  cleaned  out  by  washing  the  scalp  with  a  2  per 
cent,  solution  of  biborate  of  soda.  After  the  head  has  been 
cleaned  a  mild  stimulant  should  be  used.  The  best  for  this  pur- 
pose is  tincture  of  cantharides,  capsicum  or  jaborandi,  using  1 
dram  of  the  tincture  to  4  ounces  of  water.  Alcohol,  bay  rum, 
glycerin  and  other  desiccants  which  are  useful  in  seborrhea  are 
harmful  in  senile  alopecia.  The  fat  or  oil  should  be  used  only 
after  the  scalp  is  thoroughly  dried.  It  may  be  mentioned  here 
that  when  hair  oils,  which  consisted  of  animal  fats,  were  used, 
alopecia  was  far  less  prevalent  than  now. 

Hypertrichosis 

Excessive  growth  of  hair  or  a  growth  of  hair  in  unusual  places 
is  a  senile  phenomenon  which  cannot  be  explained  by  any  theory 
of  senescence.  It  occurs  most  frequently  upon  the  upper  lip  of 
women,  appearing  during  or  soon  after  the  menopause,  and  in 
the  ears,  nose  and  eyebrows  of  men.  The  hair  is  generally  of 
the  same  color  as  the  hair  of  the  head  and  it  retains  its  color 
long  after  the  earlier  hair  has  turned  white.  It  has  no  signifi- 
cance and  nothing  ought  to  be  done  to  remove  the  new  growth. 
If  epilation  is  desired,  the  only  effective  measure  is  electrolysis. 
This  may,  however,  leave  unsightly  spots.  The  ordinary 
depillatories  do  not  destroy  the  roots  and  they  may  produce  in- 
flammation and  possible  ulceration. 

Canites 

Canites  or  whitening  of  the  hair  is  a  senile  manifestation, 
although  it  appears  occasionally  as  early  as  the  fourth  decade. 


134  PATHOLOGICAL   OLD    AGE 

The  cause  is  unknown.  Metchnikoff  has  shown  that  chromo- 
phages  invade  the  hair  cylinder  and  carry  off  the  pigment,  but 
in  many  cases  no  such  organisms  can  be  found.  Cases  of 
sudden  whitening  of  the  hair  are  occasionally  reported  and  these 
seem  to  support  the  theory  that  the  coloring  matter  can  be 
destroyed  through  nervous  influence.  It  is,  however,  still  un- 
decided if  such  influence  exists  or  if  such  reports  are  warranted 
by  facts.  Canites  generally  proceeds  slowly  and  it  cannot  be 
halted.  Nothing  has  yet  been  found  to  take  the  place  of  hair 
dyes. 

Changes  in  the  Sudoriparous  Glands. 

There  is  generally  atrophy  of  the  glands  with  diminished  se- 
cretion. Occasionally  there  is  excessive  secretion  in  some 
localities  as  in  the  axillae,  about  the  genitals  and  anus,  and  be- 
tween the  toes,  and  the  secretion  may  have  a  fetid  ordor.  Owing 
to  impaired  sense  of  smell  this  odor  may  not  be  obvious  to  the 
patient  though  it  be  extremely  powerful  and  disagreeable. 

Treatment. — Amidrosis  or  deficiency  in  the  secretion  of  sweat 
rarely  requires  treatment.  Complete  suppression  occurs  only 
in  fevers  and  in  nephritis,  never  as  a  purely  senile  condi- 
tion. If  a  diaphoretic  becomes  necessary,  pilocarpin  should  not 
be  employed.  Hyperidrosis,  excessive  sweating,  is  seldom  so 
marked  as  to  require  treatment.  It  can  generally  be  controlled 
by  applying  a  mixture  of  equal  parts  of  salicylic  acid  and  zinc 
stearate  or  one  part  of  tannoform  to  four  parts  talcum.  Bella- 
donna ointment  will  suppress  the  secretion  but  it  may  suppress  it 
completely  and  permanently  and  this  may  be  as  undesirable  as 
the  excessive  secretion.  If  there  is  intertrigo  an  ointment  of 
zinc  oxide  2  drams  to  vaseline  6  drams  should  be  used  and  the 
parts  separated  by  a  piece  of  oiled  silk. 

Bromidrosis,  fetid  sweat  should  be  treated  like  hyperidrosis. 
The  surface  should  be  washed  with  a  1  to  30  solution  of  formalde- 
hyde before  applying  the  ointment  or  dusting  powder. 

SENILE  MUSCULAR  DEGENERATION 

While  progressive  atonicity  and  waste  of  muscular  fiber  is 
part  of  the  normal  process  of  involution  we  find  occasionly  rapid 
or  early  muscle  waste  and  we  may  get  a  pronounced  atonicity 
proceeding  to  complete  paralysis.     We  may  find  such  paralysis 


SENILE   MUSCULAR   DEGENERATION 


135 


due  to  lessened  irritability  of  the  muscle  fiber  without  impair- 
ment of  the  nerve  supply.  In  muscles  that  are  not  much  em- 
ployed fatty  granules  deposit  in  the  connective  tissue  spaces 
and  this  fatty  infiltration  keeps  pace  with  the  waste  of  muscle 
fibers.  Fatty  degeneration  is  a  pathological  process  due  to  some 
disease.  The  pathological  progressive  muscular  atrophy  of  the 
young  is  extremely  rare  in  old  age.  We  find  as  normal  mani- 
festations of  senile  degeneration  of  muscle,  simple  atrophy, 
atrophy  with  fatty  infiltration  and  functional  impairment,  di- 
minished strength,  slowed  and  weakened  reaction  and  lessened 
electrical  reaction. 

We  sometimes  find  that  the  functional  impairment  is  greater 
than  the  atrophy  would  account  for  and  in  these  cases  there  is 
generally  fatty  infiltration  and  diminution  of  nervous  irrita- 
bility.    This  if  excessive,  forms  a  distinct  disease. 

Progressive  muscular  enfeeblement  of  the  aged  is,  accord- 
ing to  Oppenheim,  due  to  a  multiple  neuritis,  while  Vulpian 
and  Donand  have  shown  that  there  is  always  a  fatty  degenera- 
tion of  the  muscle  when  this  condition  exists. 

Etiology. — There  is,  in  addition  to  the  normal  enfeeblement 
due  to  senile  waste,  some  depressive  mental  or  physical  influence 
present.  It  may  be  the  mental  depression  caused  by  the  reali- 
zation of  ageing  or  it  may  be  shock,  fear,  prolonged  pain,  a  grave 
disease,  neurasthenia,  nerve  degeneration  or  insufficient  nu- 
trition. 

Pathology. — The  muscle  is  pale,  soft,  flabby  and  has  a  greasy 
feel.  The  fibers  are  atrophied,  their  elasticity  is  diminished  and 
their  striations  barely  distinguishable.  There  is  a  deposit  of 
fat  granules  between  the  fibers.  No  nerve  lesions  have  been 
demonstrated. 

Symptoms. — There  is  a  general  progressive  weakness,  not 
localized,  proceeding  more  rapidly  than  the  age  and  the  ana- 
tomical changes  would  justify.  Slight  exertion  causes  fatigue 
from  which  recuperation  is  slow  and  not  complete.  As  the 
disease  progresses  the  fatigue  becomes  permanent,  and  any 
exertion  becomes  irksome,  finally  the  patient  is  too  weak  to 
arise  from  bed.  There  is  the  will  but  not  the  power  to  move, 
therein  differing  from  neurasthenia  in  which  the  will  is  impaired 
but  under  some  stimulus,  the  patient  will  move  and  act  as 
powerfully  as  in  health. 


136  PATHOLOGICAL   OLD   AGE 

While  the  disease  is  strictly  confined  to  the  muscles,  the 
lack  of  activity  causes  involvement  of  other  tissues.  Owing  to 
lessened  activity  and  the  consequent  lessened  waste,  less  food  is 
required  and  the  diminished  metabolic  activity  causes  less  heat 
formation.  The  temperature  is  consequently  lower,  the  cir- 
culation is  slower,  aeration  proceeds  more  slowly,  gastric  diges- 
tion is  retarded  and  there  is  less  elimination  of  waste.  Thus 
various  organs  and  tissues  become  impaired  through  lack  of 
activity  and  fatty  infiltration  results  in  them.  When  the 
disease  has  progressed  to  such  extent  that  the  patient  will  not 
get  out  of  bed,  there  is  danger  of  hypostatic  congestion  followed 
by  pulmonary  edema,  of  bed  sores  and  infection,  constipation 
with  autointoxication  or  of  retention  of  urine.  The  feebleness 
may  proceed  to  fatal  exhaustion. 

Treatment. — The  stimulation  of  muscle  irritability  is  the 
primary  indication.  This  can  sometimes  be  done  by  massage, 
coarse  vibration  or  the  galvanic  current.  Where  the  cause  was 
mental  depression  psychic  measures  may  avail.  In  some  cases 
persuasion,  suggestion  or  harsh  measures  like  threats,  a  sudden 
scare  or  disagreeable  medication  will  be  effectual.  Harsh 
measures  should  never  be  employed  except  as  a  last  resort  and 
then  only  when  the  physician  is  certain  that  the  weakness  is 
not  due  to  excessive  waste  or  to  some  pathological  condition  of 
the  structure  of  the  muscle.  If  drug  treatment  is  required  we 
must  first  determine  the  condition  of  the  muscles  and  nerves. 
Where  there  is  marked  fatty  infiltration,  the  iodides  are  required. 
They  favor  destructive  metabolism  and  if  combined  with  passive 
exercise  they  will  bring  about  waste  of  fat.  At  the  same  time 
strychnine,  phosphorus,  small  quantities  of  alcohol  and  other 
nerve  stimulants  should  be  used  and  if  the  hemoglobin  per- 
centage is  reduced,  hemoglobin  should  be  added. 

Localized  muscle  weakness  if  not  due  to  traumatism  is 
almost  always  due  to  degeneration  of  the  nerve  supplying  the 
part. 

SENILE  ARTHROSCLEROSIS 

This  disease,  first  described  under  the  term  senile  rheuma- 
tism, is  a  hardening  and  stiffening  of  the  joints  due  to  the  senile 
changes  in  the  tissues  forming  the  joint. 

Pathology. — The  tendons  are  hardened,  there  is  ossification 


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SENILE   ARTHROSCLEROSIS  137 

and  sometimes  calcification  of  cartilages,  the  cartilages  covering 
the  articular  surfaces  waste  through  attrition  and  fibrillation, 
the  ligaments  harden  and  shorten  and  the  synovial  sacs  become 
dry. 

Symptoms. — The  joint  gradually  becomes  stiff  but  there  is 
never  complete  anchylosis.  The  joint  is  not  swollen,  reddened 
or  inflamed.  There  is  no  pain  when  it  is  at  rest  but  there  is 
an  ache  upon  motion,  the  pain  and  stiffness  increasing  with  in- 
creasing or  prolonged  motion.  Sudden  severe  motion  produces 
a  severe  pain.  As  the  patient  becomes  weaker  motion  becomes 
more  irksome  owing  to  the  increasing  stiffness  of  the  joints. 

Diagnosis. — Arthrosclerosis  senilis  is  frequently  mistaken 
for  chronic  rheumatism.  There  is  no  history  of  rheumatic  fever, 
the  pains  do  not  get  worse  at  night,  there  is  no  pain  when  the 
body  is  at  rest  and  there  are  no  paroxysmal  attacks  of  pain. 
The  pain  and  stiffness  of  chronic  rheumatism  is  lessened  upon 
motion  or  upon  "limbering  up,"  as  the  patient  calls  it. 

Owing  to  the  difficulty  in  arising  from  a  sitting  position, 
this  disease  is  often  diagnosed  as  lumbago  or  myalgia.  In  the 
senile  condition  there  is  hardening  and  stiffening  of  the  vertebral 
joints  with  waste  of  the  muscles  of  the  back,  but  no  myositis. 
The  ache  becomes  progressively  more  severe  but  there  is  no 
pain  when  the  patient  is  at  rest  or  turns  in  bed.  In  myalgia 
the  pain  comes  on  suddenly,  is  generally  severe,  at  times 
paroxysmal  with  painless  remissions,  while  in  lumbar  myalgia, 
turning  in  bed  is  painful. 

Treatment. — While  the  salicylates  and  local  counterirritants 
are  of  benefit  in  the  rheumatic  conditions  they  are  absolutely 
useless  in  the  senile  condition.  The  treatment  in  these  cases 
is  purely  empirical;  in  some  cases  psychic  methods  in  some 
hydrotherapy,  in  some  drug  treatment,  is  effective.  Hot 
baths  or  hot  applications  over  the  joints  followed  by  inunction 
with  an  animal  oil  or  fat  is  often  beneficial.  In  some  cases 
the  best  results  are  obtained  from  mild  or  coarse  massage  or 
vibratory  treatment.  The  internal  medication  must  be  directed 
to  overcome  the  senile  debility,  phosphorus,  arsenic,  strychnine, 
hemoglobin,  etc.  Occasionally  psychic  influences  are  more 
effective  than  drugs  and  among  such  influences  must  be  in- 
cluded the  empirical  use  of  liniments  which  the  patients  them- 
selves employ.     The  local  use  of  alcohol  is  contraindicated. 


138  PATHOLOGICAL   OLD    AGE 

PSEUDO-PAGET'S  DISEASE 

This  name  is  a  misnomer,  the  disease  being  a  rare  form  of 
osteoporosis  occurring  in  old  age.  The  head  is  held  forward, 
the  knees  are  slightly  flexed,  and  the  legs  are  spread  apart. 
The  hands  are  held  out  from  the  body,  there  are  deformities 
in  the  lower  limbs  and  trunk,  the  angle  of  Louis  in  the  sternum 
is  prominent,  and  the  whole  thorax  seems  to  be  pushed  down 
into  the  abdomen.  The  latter  shows  a  rounded  eminence  in 
the  epigastrium  and  hypogastrium,  deep  transverse  folds  above 
the  umbilicus  ending  laterally  in  depressions  in  the  hypo- 
chondriac area,  and  a  diminution  or  obliteration  of  the  space 
between  the  ribs  and  the  crest  of  the  ilium.  The  spinal  column 
shows  one  curve  with  the  convexity  posteriorly.  When  the 
heels  are  held  together  the  internal  condyles  of  the  femurs  are 
far  apart.  The  general  appearance  is  that  of  Paget's  disease 
but  it  occurs  much  later  in  life,  generally  in  the  eighth  decade. 
It  is  apparently  an  extreme  type  of  senile  degeneration  of  the 
bones  and  a  disease  to  the  extent  of  producing  discomfort  and 
deformities.  There  is  no  treatment,  but  braces  and  a  cane  can 
retard  the  changes  and  prevent  the  stoop. 

SENILE  DEGENERATION  OF  THE  BRAIN 

Senile  Dementia 

The  ordinary  senile  changes  in  the  brain  have  been  described 
in  the  chapters  on  Anatomy  and  Physiology.  In  many  cases 
more  profound  histological  and  physiological  changes  occur  and 
give  rise  to  symptoms  for  the  relief  of  which  medical  care  is 
indicated.  We  must  remember,  however,  that  there  is  but  little 
relationship  between  the  organic  and  the  functional  changes, 
that  mentality  depends  upon  some  unknown  quality  of  the 
brain  cells  and  not  upon  size  of  brain  or  amount  of  brain  sub- 
stance, that  brain  substance  has  been  lost  without  alteration  of 
mentality  or  sensory-motor  impairment.  Memory  is  most 
active  during  the  period  of  development,  while  reason  and 
judgment  increase  for  years  after  the  brain  has  reached  the 
limit  of  growth  and  even  while  it  is  in  the  process  of  atrophy. 
In  some  the  comparative  and  constructive  faculties  remain 
unimpaired    to    the    end    of    life    while    the    conservative    fa- 


Pseudo-paget's   Disease. 


Xouvelle   Iconographie  ' de  la   Salpetriere, 
Jan.-Feb.,  1905. 


SENILE    DEGENERATION   OF    THE  BRAIN  139 

culty  shows  diminished  power  even  before  the   completion  of 
development. 

Etiology. — The  diminution  in  the  weight  of  the  brain  begins 
normally  about  the  end  of  the  fourth  decade  of  life,  soon  after 
it  has  reached  its  greatest  weight  and  years  before  the  atrophy 
could  reasonably  be  charged  to  diminished  nutrition  from 
cerebral  arteriosclerosis.  The  causes  that  prevail  in  old  age, 
such  as  impaired  nutrition  and  neurophages,  do  not  prevail 
when  the  atrophic  changes  begin  and  no  theory  has  been  ad- 
vanced to  explain  it.  As  most  of  the  psychic  and  somatic 
functions  increase  for  a  time  after  the  brain  begins  to  atrophy, 
it  is  reasonable  to  assume  that  the  waste  begins  in  those  cells 
controlling  the  functions  that  are  lessened  about  this  time. 
In  what  portion  of  the  brain  these  cells  are  located  is  unknown. 

We  find  that  organs  and  tissues  which  have  been  insufficiently 
employed  and  those  which  have  been  used  excessively  break 
down  early.  Activity  demands  increased  blood  supply  to  re- 
pair waste,  and  inactivity  lessens  the  circulation  in  the  part. 
Prolonged  inactivity  causes  a  lessened  supply  of  blood  and  a 
slowed  circulation  with  the  inevitable  result  of  deficient  nutri- 
tion and  waste  of  tissue.  Excessive  activity  hastens  degenera- 
tion partly  through  fatigue  toxins,  partly  through  incomplete 
repair.  There  may  be  also  a  hastening  in  the  evolution  of 
tissue  cells,  causing  a  more  rapid  development  of  the  cells  of 
an  advanced  evolutionary  stage. 

The  same  causes  may  apply  to  the  brain  cells.  Persons  of 
low  mentality,  such  as  the  uneducated  peasants,  find  it  almost 
impossible  to  learn  anything  new  after  their  thirtieth  or  thirty- 
fifth  year.  They  may  retain  the  memory  of  events  that  have 
made  a  powerful  impression  upon  them  but  they  cannot  learn 
a  new  language,  though  spending  years  among  those  who 
speak  that  language.  In  these  persons  the  cells  involved  in 
memory  become  functionless  from  disuse  and  if  the  same  process 
goes  on  in  them  that  goes  on  in  functionless  cells  of  other  tissues 
they  waste.  If  on  the  other  hand  the  conservative  faculty  has 
been  excessively  employed,  a  rapid  deterioration  will  occur  when 
the  functional  capacity  of  the  cells  has  been  exceeded.  As  the 
mentality  differs  in  different  individuals,  the  functional  capacity 
differs.  One  child  will  get  brain  fag  from  studying  the  same 
lesson  that  another  child  of  the  same  age  acquires  without 


140  PATHOLOGICAL   OLD    AGE 

difficulty.  The  enormous  amount  of  information  acquired  by 
the  child  can  be  gleaned  by  comparing  the  school  curriculums, 
age  for  age,  of  today  with  the  curriculums  of  forty  years  ago. 
The  increase  represents  only  the  additional  information  ac- 
quired since  that  time.  The  result  is  that  the  conservative 
faculty  is  excessively  employed  and  by  the  time  that  brain 
development  is  complete  and  other  faculties  are  fully  active, 
this  faculty  begins  to  become  impaired  and  it  is  probable  that 
the  cells  engaged  begin  to  degenerate. 

When  the  circulatory  changes  of  advancing  age  are  active 
and  the  nutrition  of  the  brain  is  impaired,  the  cell  degeneration 
proceeds  more  rapidly,  reason  and  judgment  become  impaired, 
and  at  the  same  time  the  somatic  functions  become  weakened. 
Metchnikoff  has  shown  the  influence  of  neurophages  upon  brain 
cells  but  it  is  not  at  all  certain  that  these  phagocytes  appear 
in  every  senile  case.  When  they  are  present  they  are  a  potent 
factor  in  causing  tissue  waste. 

Pathology. — There  are  marked  changes  in  the  brain  tissue  and 
in  the  vessels.  The  changes  in  the  latter  have  been  described 
under  Arteriosclerosis.  The  extent  of  the  arterial  degeneration 
varies,  in  some  cases  only  the  small  vessels  and  capillaries  being 
involved,  in  others  the  large  vessels  alone  or  the  whole  arterial 
system  of  the  brain  is  affected.  Miliary  aneurysms  are  frequent. 
The  changes  are  fairly  uniform  in  character  but  differ  in  degree. 
When  they  are  far  advanced  the  weight  of  the  brain  may  be  200 
grams  below  the  weight  of  maturity,  the  waste  being  principally 
in  the  frontal  lobes,  the  cerebrospinal  fluid  is  increased,  the  pia 
mater  is  thickened  over  the  entire  cortex,  contains  amyloid  bodies 
and  plaques  of  calcareous  matter,  the  dura  adheres  to  the  bone 
and  there  may  be  a  pachymeningitis  interna.  The  convolutions 
may  be  edematous,  the  sulci  are  shallow,  gaping  and  filled  with 
adventitious  pia.  Minute  hemorrhages  are  often  found  in  the 
cortex  and  basal  ganglion  which  form  the  foci  for  softening.  The 
spongy  sieve-like  appearance  described  as  Etat-Crible  is  present. 
The  ventricles  are  dilated  and  the  ependymal  wall  is  thickened. 
There  is  a  hypertrophy  of  the  neuroglia,  and  atrophy  of  the  cor- 
tical neurones.  The  cell  bodies  become  shrunken  and  diminished 
in  number  and  the  processes  become  tortuous,  narrow  and  short. 
The  physiological  increase  in  yellow  pigment  in  the  cells  may 
proceed   to  pigmentary   degeneration.     The   changes  here  de- 


SENILE   DEGENERATION    OF   THE   BRAIN  141 

scribed  are  present  in  advanced  cerebral  degeneration  such  as  is 
usually  found  in  senile  dementia. 

Symptoms. — The  functional  changes  in  the  senile  brain 
include  mental  deterioration  and  physical  impairment.  In 
determining  the  extent  of  senile  impairment,  the  normal  men- 
tality of  the  individual  should  be  known.  The  impairment, 
though  manifested  in  many  directions,  may  progress  for  years 
before  it  becomes  obvious  to  friends  and  the  family  who  con- 
stantly surround  him.  An  early  symptom  of  the  deterioration 
is  a  hesitancy  in  recalling  names,  dates  and  events,  fabricating 
others  if  the  patient  thinks  the  fabrication  will  not  be  discovered. 
The  fictitious  name,  date  or  event  will  probably  be  forgotten 
the  next  day  and  if  the  right  answer  is  not  recalled  the  new 
name,  date  or  event  will  also  be  forgotten  and  another  substi- 
tuted. The  patient  will  forget  where  he  puts  things,  will  repeat 
questions  that  had  just  been  answered,  forget  the  names  of 
persons  to  whom  he  had  just  been  introduced,  and  if  interrupted 
while  speaking  he  will  forget  where  he  left  off  or  he  may  forget 
the  subject  altogether.  Attention  is  defective  and  prolonged 
effort  to  maintain  attention  leads  to  brain  fag.  The  aged  person 
who  falls  asleep  during  the  play  or  sermon  does  so  through 
excessive  attention  with  consequent  brain  fag  and  not  through 
inattention  or  indifference.  He  must  make  a  sensible  effort  to 
understand  the  connection  between  things  where  such  connections 
ought  to  be  instantly  obvious.  He  becomes  careless  about 
details  and  loses  the  sense  of  neatness,  leaving  his  desk  disordered 
his  room  untidy,  his  clothes  disarranged.  Business  and  social 
affairs  are  not  clearly  comprehended  and  this  gives  rise  to  errors. 
Errors  in  playing  cards,  usually  charged  to  inattention,  errors 
in  calculation,  charged  to  carelessness,  slips  of  the  tongue, 
absent-mindedness,  etc.,  are  due  to  inability  to  concentrate 
attention  to  one  object.  He  becomes  egotistic,  exaggerates 
his  own  importance  and  his  interests,  becomes  sensitive  to  what 
he  considers  to  be  neglect  of  himself  or  his  interests  and  thus 
dislike,  hatred,  fear  and  finally  oikiomania  are  developed.  This 
may  proceed  to  delusions  of  persecution. 

There  is  generally  a  pronounced  change  in  temperament 
and  emotional  attitude.  There  is  frequently  depression  due 
either  to  the  recognition  of  waning  powers  and  the  nearness  of 
the  closing  period  of  life,  or  to  fancied  neglect.     The  patient 


142  PATHOLOGICAL   OLD    AGE 

becomes  peevish  and  irritable  and  will  exhibit  anger  upon  the 
slightest  provocation.  Elation  is  rare.  His  self-interest  de- 
stroys interest  in  others  and  while  he  may  show  external  sym- 
pathy by  weeping  there  is  rarely  profound  grief  or  joy  and  these 
are  soon  forgotten.  The  aged  take  frequent  naps  during  the 
day,  as  mental  and  physical  fatigue  set  in  quickly  upon  activity, 
and  at  night  they  are  often  restless  and  walk  about  aimlessly 
or  they  will  repeatedly  try  doors  and  windows,  search  through 
closets,  desks,  trunks,  etc.,  without  any  object.  Inability  to 
accommodate  himself  to  a  progressive  order  of  things  is  a  fre- 
quent accompaniment  of  old  age.  While  there  is  general  mental 
decadence,  in  some  cases  the  reasoning  faculties  are  not  im- 
paired and  where  the  mental  efforts  are  all  directed  into  one 
channel,  remarkable  work  may  be  done  in  this  one  direction, 
but  in  other  directions  the  impairment  is  more  pronounced. 
What  are  usually  looked  upon  as  whims,  hobbies  and  peculiari- 
ties of  great  men  of  advanced  age  are  really  manifestations  of 
mental  impairment.  A  deeper  grade  of  mental  impairment 
often  seen  in  the  senile  climacteric  is  senile  confusion.  This 
condition  is  marked  by  disorientation.  The  patient  walks 
aimlessly  and  unconsciously,  oblivious  of  his  surroundings  and 
often  in  dangerous  localities;  and  if  he  can  be  roused,  mental 
clearness  is  awakened  but  almost  immeditely  dissipated.  He 
loses  track  of  time,  distance  and  direction,  goes  out  in  winter 
without  a  coat,  may  undress  in  the  street,  speak  to  strangers, 
especially  to  children,  talking  senseless  drivel.  Memory  may 
be  so  weakened  that  he  forgets  his  own  name  and  if  spoken  to 
he  shows  by  his  answers  that  he  cannot  comprehend  or  com- 
prehends but  imperfectly  the  import  of  the  question.  He 
is  garrulous  but  there  is  incoherence  of  thought  with  gradually 
deepening  impairment  of  comprehension  until  the  condition 
of  complete  dementia  is  reached.  In  this  condition  the  indi- 
vidual resembles  either  the  absolute  idiot  who  had  never  had 
a  trace  of  intelligence  and  is  consequently  quiet,  or — as  in 
terminal  dementia — is  moving  automatically,  mumbling,  with 
occasional  outbursts  of  silly  laughter,  shrieks,  etc. 

Senile  delirium  occurs  occasionally  during  the  senile  climac- 
teric. It  is  marked  by  hallucinations  and  great  activity. 
There  are  usually  the  symptoms  of  senile  confusion  with  short 
attacks  of  delirium  during  which  there  are  delusions  and  hallu- 


SENILE   DEGENERATION   OF   THE   BRAIN  1 43 

cinations  that  are  forgotten  when  the  remission  occurs.  In 
some  cases  the  attacks  come  on  suddenly;  the  patient  sitting  or 
walking  quietly  begins  to  shout  or  sing,  walks  rapidly  up  and 
down  the  room,  seeing  things  or  hearing  strange  sounds.  In 
other  cases  the  attack  comes  on  gradually  with  restlessness  and 
increasing  activity.  Prostration  may  occur,  but  usually  the 
attack  subsides  gradually  until  the  patient  is  quiet.  On  rare 
occasions  the  mind  clears  up  for  a  short  time. 

Senile  dementia  in  its  medicolegal  relations  will  be  treated 
under  that  chapter. 

The  somatic  derangements  due  to  cerebral  degeneration 
have  not  been  clearly  defined.  Impaired  coordination  is 
generally  of  cerebral  origin  and  senile  tremor,  the  increasing 
physical  weakness,  paraplegia  and  diverse  impairments  of  the 
senses  and  sensation  may  be  due  wholly  or  partly  to  cerebral 
degeneration.  Impairment  of  sensation  and  of  the  special 
senses  is  often  due  to  a  weakened  mind,  which  does  not  readily 
interpret  the  impressions  received.  We  sometimes  find  that 
under  an  extraordinary  mental  stimulus,  as  the  fear  of  death  in 
a  burning  building,  the  mind  clears  up,  the  senses  become 
normal  and  even  strength  may  be  temporarily  restored.  In 
such  cases  the  effort  is  but  momentary  and  is  followed  by  pro- 
found reaction. 

Treatment. — True  senile  dementia  is  progressive  and  incur- 
able, but  much  can  be  done  in  the  early  stages  of  mental  dete- 
rioration to  impede  its  progress,  and  in  advanced  stages  it  is 
sometimes  possible  to  temporarily  rouse  the  individual  to  a 
comprehension  of  his  surroundings  and  his  condition. 

The  keynote  of  treatment  is  mental  stimulation.  This  is 
opposed  to  the  usual  treatment  of  this  condition  by  rest  and 
quiet.  Unless  it  is  a  terminal  dementia  which  requires  the 
constant  presence  of  an  attendant  and  mentality  is  so  far  gone 
that  no  impression  can  be  made  upon  it,  the  patient  should  not 
be  placed  among  insane  patients  nor  immured  in  an  asylum. 
Our  object  should  be  to  rouse  the  patient  to  take  an  interest  in 
something  else  than  in  his  body  and  his  fate.  His  mental  facul- 
ties should  be  constantly  employed  until  brain  fag  sets  in,  but 
mental  confusion  should  be  avoided.  To  give  a  homely  illus- 
tration, he  may  watch  a  one-ring  circus  until  after  a  time  brain 
fag  will  set  in  and  he  will  fall  asleep.     If  he  tries  to  watch  a 


144  PATHOLOGICAL   OLD   AGE 

three-ring  circus  there  will  be  mental  confusion,  possibly  delu- 
sions, and  insomnia.  Pleasurable  sensations  should  be  pro- 
duced, especially  such  as  the  patient  is  familiar  with.  An  old 
popular  song  will  often  rouse  an  aged  person  out  of  lethargy, 
and  this  is  one  of  the  most  effectual  means  to  bring  about  a 
temporary  clearing  of  the  intellect.  The  concert,  ballet  or  what- 
ever else  will  produce  harmony  of  color,  sound  or  motion  will  be 
beneficial.  The  monotonous  routine  of  the  asylum  hastens 
dulling  of  the  intellect  and  the  association  with  insane  will  rouse 
delusions.  As  the  deterioration  increases  a  constant  change  of 
environment,  of  sight,  scenes  and  sounds  is  necessary.  If  there 
is  mental  confusion  it  will  be  necessary  to  place  the  patient  in  a 
position  where  the  attention  can  be  concentrated  upon  one 
object  alone,  a  view  of  the  sea  or  distant  mountains,  a  familiar 
song,  or  poem,  a  favorite  child  or  grandchild,  etc.,  changing  the 
object  from  time  to  time  but  always  selecting  an  object  pleasing 
to  the  patient.  In  the  apathetic  and  melancholic  forms  of 
dementia  it  may  be  advisable  occasionally  to  subject  the  patient 
to  excitement  such  as  a  lively  seaside  resort  a  masque  ball  or 
carnival  and  though  this  will  produce  mental  confusion  it  will 
stimulate  mental  activity.  The  most  powerful  psychic  impres- 
sions are  often  produced  by  the  flattery  of  young  persons  of  the 
opposite  sex  and  there  is  probably  nothing  that  will  so  effec- 
tually produce  mental  and  physical  rejuvenescence  as  a  young 
husband  or  wife.  A  recrudescence  of  sexual  desire  in  the  aged 
without  psychic  causes,  as  pornographs,  erotic  literature,  con- 
versation or  suggestion,  is  a  symptom  of  senile  dementia.  When, 
however,  such  desire  can  be  stimulated  by  psychic  measures 
it  indicates  a  state  of  mind  susceptible  to  improvement.  We 
can  thus  explain  the  remarkable  mental  and  physical  improve- 
ment in  aged  men  who  marry  young  women. 

Of  drugs,  phosphorus  and  morphine  are  the  best  mental 
stimulants.  Morphine  in  small  doses  produces  a  mental  stimu- 
lation which  passes  off  in  a  few  minutes  or  hours.  Habituation 
is,  however,  rapidly  induced  and  if  frequently  repeated  the 
stimulating  effect  is  diminished  and  finally  lost  unless  the  dose 
is  constantly  increased.  If  this  is  persisted  in,  death  will  result 
from  morphine  poisoning.  Morphine  in  1/20-grain  dose  may 
be  used  occasionally  if  temporary  mental  stimulation  is  desired. 
Small  doses  of  cannabis  indica  will  stimulate  the  imagination, 


SENILE  DEGENERATION  OF  THE  CORD  145 

generally,  however,  in  the  direction  of  delusions  and  illusions. 
Alcohol  is  worse  than  useless.  Phosphorus  is  the  best  mental 
and  nervous  stimulant  we  have  as  it  is  positive  in  action  and 
there  is  no  habituation.  It  should  be  given  when  the  first 
symptoms  of  mental  deterioration  appear,  discontinued  when 
there  is  a  response  in  a  brighter  mental  attitude  and  resumed 
when  this  passes  away.  The  dose  of  the  ordinary  phosphorus 
is  1/100  grain  gradually  increased  to  1/20  grain,  always  in 
solution.  For  several  years  the  author  has  used  amorphous 
(red)  phosphorus  in  doses  of  1  grain  gradually  increasing  to  5 
grains  three  times  a  day. 

SENILE  DEGENERATION  OF  THE  CORD 

Senile  degeneration  of  the  cord  gives  rise  to  numerous  func- 
tional disturbances.  It  is,  however,  often  impossible  to  deter- 
mine the  relation  between  the  structural  changes  and  the  func- 
tional impairment,  as  similar  histological  changes  may  present 
the  most  diverse  symptoms,  while  similar  symptoms  may  be 
associated  with  different  forms  of  degeneration  or  in  different 
locations.  Sometimes  profound  functional  impairment  exists 
yet  no  degenerative  change  is  found  after  death  and  extensive 
areas  of  degeneration  have  been  found  upon  autopsy  which  gave 
no  symptoms  during  life.  Extensive  atrophy  of  the  cells  of  the 
anterior  horns  has  been  found  in  cases  which  gave  no  symptom 
of  progressive  muscular  atrophy  and  scattered  areas  of  sclerosis 
are  often  found  upon  autopsy  of  very  old  persons,  who  did  not 
present  the  symptoms  of  multiple  sclerosis  during  life.  In 
some  cases  degenerative  changes  will  be  found  without  symp- 
toms but  with  a  history  of  earlier  nervous  disease  which  has 
been  cured. 

The  typical  senile  degeneration  of  the  cord  is  seldom  found 
before  the  seventh  decade,  but  the  early  manifestations  of 
spinal  impairment,  weakened  and  slowed  impulses  and  tardy 
response  to  impulses,  are  observed  in  the  sixth  decade.  Dimin- 
ished irritability  and  impairment  of  the  muscle  sense  are  noted 
about  the  same  time,  weakened  coordination  and  lessened 
muscular  power  appear  later  and  still  later  senile  tremor  makes 
its  appearance.     There  is  an  increasing  weakness  in  the  lower 

limbs  which  in  extreme  cases  may  become  a  paraplegia,  but 
10 


146  PATHOLOGICAL   OLD   AGE 

senile  paraplegia  is  never  complete.  In  some  cases  the  loca- 
tion of  the  degeneration  and  the  functional  impairment  do  not 
correspond  and  we  may  have  a  degeneration  of  the  upper  part 
of  the  cord  with  no  other  symptom  than  paraplegia.  In  most 
cases,  however,  the  impairment  corresponds  with  the  degenera- 
tion of  that  part  of  the  cord  which  supplied  the  impaired  tissue. 
The  progressive  weakness  of  the  aged  is  caused  partly  by  the 
waste  of  muscle  and  partly  by  cord  and  nerve  weakness,  and 
exaggerated  by  the  mental  condition  of  the  individual.  (The 
weakness  of  the  cord  which  is  due  to  its  degeneration  will  be 
described  in  the  following  chapter  under  the  head  Senile  De- 
generative Myelitis.) 

SENILE  DEGENERATIVE  MYELITIS 

This  term  is  applied  to  senile  degeneration  of  the  cord  when 
its  manifestations  are  pronounced  enough  to  produce  distressing 
symptoms  or  profound  functional  impairment.  It  is  not  an 
inflammatory  process. 

Pathology. — There  is  usually  atrophy  of  the  ganglionic 
cells,  with  increase  of  cerebrospinal  fluid,  the  cord  as  a  whole 
is  firm  but  there  may  be  spots  or  patches  of  sclerosed  tissue  and 
occasionally  areas  of  softening  are  found.  The  motor  areas  are 
usually  first  affected. 

Symptoms. — There  is  no  uniformity  in  the  symptoms  or 
regularity  in  the  order  of  their  appearance.  The  one  symptom 
present  in  all  cases  is  a  gradual  weakening  of  the  lower  limbs, 
the  so-called  senile  paraplegia.  If  the  cervical  portion  of  the 
cord  is  affected  there  is  motor  paraplegia,  degeneration  of  the 
dorsal  portion  produces  a  spastic  paraplegia,  and  if  situated  in 
the  lumbar  portion  there  is  motor  and  sensory  paraplegia.  In 
degeneration  of  the  lumbar  portion  the  reflexes  are  diminished; 
if  there  is  dorsal  degeneration,  they  are  increased.  In  many 
cases  areas  of  degeneration  are  scattered  throughout  the  entire 
cord  and  we  may  then  find  exaggerated  or  diminished  reflexes, 
even  an  increased  knee  reflex  while  the  tendon  Achilles  reflex  is 
diminished  or  vice  versa.  The  paraplegia  comes  on  slowly,  is 
progressive  and  never  becomes  complete.  The  sphincters  are 
rarely  involved  except  when  due  to  local  causes.  Senile  para- 
plegia is  generally  associated  with  senile  abasia  and  sometimes 
with  senile  tremor. 


SENILE   DEGENERATIVE   MYELITIS  1 47 

Senile  abasia  is  the  slow  unsteady  gait  of  the  aged  when 
walking  without  a  cane  and  is  due  to  lessened  coordination, 
muscular  weakness,  bent  knees  and  the  fear  of  falling.  This 
fear  is  aroused  through  the  greater  difficulty  in  maintaining 
equilibrium  which  now  requires  a  conscious  effort.  Occasion- 
ally there  is  a  slow,  tremulous  tripping  gait,  the  "abasia  trepi- 
dante"  of  Petrens,  and  when  this  is  associated  with  senile 
tremor  and  senile  paraplegia  we  get  a  clinical  picture  resembling 
paralysis  agitans.     (For  diagnosis  see  Senile  Tremor.) 

If  the  paraplegia  is  of  cerebral  origin  there  is  instability  on 
turning  around.  There  is  also  mental  impairment  more  pro- 
nounced than  the  usual  impairment  at  the  patient's  age.  A 
myopathic  form  of  senile  paraplegia  originates  in  the  nerves  of 
the  muscles  and  produces  cramps  and  contractions  and  later  on 
atrophy.  In  the  spinal  form  there  is  no  atrophy  except  the 
usual  waste  due  to  age  and  disuse. 

The  treatment  of  senile  abasia  is  mainly  psychic.  It  is 
necessary  to  overcome  the  fear  of  falling  and  to  do  this  we  must 
improve  the  sense  of  well-being  of  the  individual.  A  cane  is 
necessary  and  it  should  be  so  long  that  the  patient  need  not 
bend  over  to  grasp  the  handle  when  the  point  on  the  ground  is 
at  the  distance  of  an  ordinary  step  from  the  body.  The  me- 
dicinal treatment  is  the  same  as  has  been  given  under  senile 
cachexia.  Rubber-heeled  shoes  should  be  used  and  ankle 
supports  and  arch  supporters  should  be  fixed  in  the  shoes  even 
if  local  conditions  do  not  make  them  necessary.  The  sense  of 
security  derived  from  their  use  will  often  overcome  the  fear  of 
falling  and  will  enable  the  patient  to  make  a  firmer  step. 

A  form  of  senile  paraplegia  which  Demange  calls  "Contrac- 
ture tabetique  progressive  des  aikeromateux"  is  characterized  by 
a  progressive  contraction  of  the  muscles  of  the  lower  extremities 
with  increased  tendon  reflex.  He  ascribes  the  disease  to  a 
degeneration  of  the  lateral  fibers  following  atheroma  of  the 
smaller  branches  of  the  spinal  artery.  The  symptoms  have 
been  found  without  the  anatomical  changes  and  the  anatomical 
changes  have  been  found  without  the  symptoms.  Sensory  im- 
pairment is  frequently  found  in  the  aged  but  it  is  often  impos- 
sible to  say  if  it  is  due  to  the  brain,  cord,  nerves  or  end  organs. 

Treatment. — As  it  is  generally  impossible  to  localize  senile 
degenerations  of  the  cord,  treatment  must  be  applied  through- 


148  PATHOLOGICAL   OLD   AGE 

out  its  length.  The  most  effective  method  of  stimulating 
spinal  activity  is  by  the  application  of  the  faradic  current  after 
moist  heat  had  been  applied.  It  is  impossible  to  restore  de- 
generate tissue  but  it  is  often  possible  to  stimulate  functional 
activity  where  it  is  lessened  and  that  is,  after  all,  the  aim  of  the 
physician  in  treating  senile  cases. 

Internal  medication  is  limited  to  phosphorus,  arsenic  and 
strychnine.  If  there  is  a  luetic  taint  the  iodide  of  arsenic  should 
be  used.  The  precautions  concerning  these  drugs,  given  in 
the  treatment  of  senile  cachexia,  must  be  observed.  Strychnine 
is  the  most  powerful  of  the  spinal  stimulants,  but  it  must  be 
given  in  constantly  increasing  doses  and  we  have  no  means  of 
overcoming  its  excessive  stimulation  of  the  heart.  That  organ 
must  be  watched  when  giving  strychnine.  Palpitation  or 
increased  blood  pressure  is  the  indication  to  stop  its  use.  Cold 
sponges  are  harmful.  Occasionally  some  intense  psychic  im- 
pression will  temporarily  restore  the  power  and  sensibility  of 
the  limbs. 

SENILE  TREMOR 

This  is  a  neurosis  for  which  no  pathological  lesion  has  been 
found,  nor  is  there  much  known  concerning  its  etiology.  Pic 
says  it  is  a  manifestation  of  an  irritable  enfeeblement  of  the 
nervous  system  of  the  neuropath.  In  most  cases  there  is  a 
neurotic  taint,  occasionally  hereditary;  more  often  there  is  a 
history  of  antecedent  nervous  disease.  (It  is  placed  in  the 
first  group  on  the  assumption  that  it  is  a  manifestation  of 
general  debility  and  a  symptom  of  advanced  senile  degenera- 
tion of  the  cerebrospinal  system.)  Some  cases  are  traceable 
to  suggestion  or  mimicry. 

Symptoms. — Senile  tremor  generally  begins  with  an  unsteadi- 
ness of  the  hand  which  has  done  the  most  work,  then  both 
hands  are  affected  and  slight  muscular  exertion  causes  them  to 
tremble.  Later  the  head  and  neck  muscles  are  involved.  The 
lower  limbs  are  rarely  affected  except  after  considerable  exer- 
cise, such  as  a  long  walk,  taking  long  steps,  climbing  stairs  or 
swinging  the  legs  when  bent  at  the  knee.  It  is  a  slow  inten- 
tion tremor,  the  oscillations  not  exceeding  five  per  second,  and 
coming  on  only  during  the  voluntary  contraction  of  the  muscles. 
The  tremor  is  most  noticeable  in  the  head  and  neck  muscles, 


SENILE    TREMOR 


149 


there  being  a  coarse  tremor  of  the  head,  a  fine  tremor  of  the  lips, 
and  a  shaking  or  trembling  of  the  lower  jaw.  The  shaking  of 
the  head  is  generally  in  an  up  and  down  (vertical)  direction 
but  a  tremor  in  a  horizontal  direction  and  even  a  rotary  motion 
have  been  observed.  The  tremor  of  the  lower  jaw  resembles 
the  motion  of  mumbling,  occasionally  that  of  chewing. 

The  tremor  is  increased  upon  excitement  or  exertion  but 
may  be  temporarily  controlled  by  the  will.  In  some  cases  the 
tremor  is  confined  to  the  hands  during  voluntary  motion. 

The  head  does  not  tremble  when  supported  by  the  hand 
and  the  tremor  ceases  during  sleep. 

Diagnosis. — Senile  tremor  is  diagnosed  from  paralysis  agi- 
tans  by  the  absence  of  the  characteristic  attitude,  gait,  muscle 
stiffness,  cramps,  forward  pitch,  posture  of  the  hands  and  the 
immobile  facial  expression  of  the  latter  disease.  If  senile  tremor 
is  associated  with  abasia  trepidante,  there  may  be  a  similar 
gait  and  a  tendency  to  pitch  forward,  but  the  other  symptoms 
of  paralysis  agitans  are  absent.  The  tremor  of  the  hands  in 
senile  tremor  resembles  the  tremor  of  disseminated  sclerosis 
but  the  latter  is  a  disease  of  early  and  middle  life,  and  is  charac- 
terized by  a  spastic  gait,  a  rapidly  increasing  weakness,  nystag- 
mus with  other  ocular  symptoms,  and  peculiar  scanning 
speech,  all  of  which  are  absent  in  senile  tremor.  The  toxic 
tremors,  as  from  alcohol,  tobacco,  lead,  mercury,  etc.,  are  inten- 
tion tremors  but  the  history  and  accompanying  symptoms 
readily  distinguish  them  from  senile  tremor.  In  hysterical 
tremor  other  symptoms  of  hysteria  and  the  absence  of  tremor 
when  the  attention  is  diverted,  determine  the  diagnosis. 

Treatment. — Drugs  useful  in  other  tremors  have  no  effect 
upon  senile  tremor.  Neither  hyoscine,  hyoscyamine,  duboisine, 
the  bromides  nor  iodides  are  of  any  use.  The  only  drugs  which 
seem  to  have  any  effect  are  arsenic  and  strychnine  in  gradually 
increased  doses  to  the  limit  of  tolerance  of  the  former  and  until 
palpitation  of  the  heart  indicates  that  the  strychinne  is  acting 
unfavorably  upon  that  organ.  Psychic  measures,  especially 
flattery,  will  sometimes  cause  arrest  of  the  tremors  by  concen- 
trating attention  to  them  and  rousing  a  persistent  effort  to 
control  them.  If  the  tremor  is  due  to  imitation,  harsh  meas- 
ures, such  as  threats,  deprivation  of  food,  etc.,  may  be  necessary 
to  effect  a  cure. 


150  PATHOLOGICAL    OLD    AGE 

SENILE  DEGENERATION  OF  THE  NERVES  AND 

END  ORGANS 

Pathology. — The  degenerative  changes  in  the  nerves  are  a 
hyperplasia  of  the  neuroglia  and  an  atrophy  of  the  nerve  cells 
and  fibrils,  more  marked  in  the  terminal  fibers  and  diminishing 
toward  the  center.  The  senile  changes  in  the  nerves  appear 
late  in  life,  indeed  in  many  cases  no  histological  changes  can  be 
found  to  account  for  symptoms  evidently  due  to  the  nerves. 
It  is  often  impossible  to  say  whether  a  neuralgia,  local  paralysis, 
motor  or  sensory  impairment,  tremor  or  reflex  perversion  is 
due  to  cerebral,  spinal,  nerve  or  end  organ  defect.  In  some 
cases  giving  the  symptoms  of  neuritis  we  can  find  the  patho- 
logical changes  observed  in  chronic  interstitial,  parenchymatous 
or  multiple  neuritis  but  in  most  of  these  cases  we  can  discover 
an  etiological  factor  besides  senile  involution. 

Symptoms. — The  functional  activity  of  the  nerves  is  dim- 
inished, motor  impulses  are  slowed  and  weakened,  sensibility  is 
lessened,  the  special  senses  are  impaired  and  the  functions  of  the 
regulation  centers  are  slowed,  weakened  and  sometimes  per- 
verted. The  loss  of  muscular  strength  is  due  partly  to  the  nerve 
changes  and  partly  to  waste  of  muscle  and  lessened  muscle  irri- 
tability. The  impairment  of  the  special  senses  may  be  due  to 
degeneration  of  the  afferent  nerves  or  it  may  be  due  to  some 
change  in  the  end  organs  or  in  the  brain.  It  is  probable  that 
the  nerves  and  end  organs  are  both  involved  while  the  brain  is 
less  able  to  receive  and  interpret  sensory  impressions.  Fear 
exaggerates  the  sensation  of  pain  and  the  aged  complain  of 
acute  pains  where  the  local  condition  does  not  give  rise  to  much 
pain.  The  patient  may  complain  of  intense  pain  from  a  scratch 
which  he  can  see,  yet  he  will  hardly  notice  the  pain  from  a  peri- 
tonitis, pleurisy  or  acute  gout  when  he  cannot  see  the  diseased 
tissue.  Suggestion  and  mimicry  will  give  rise  to  painful  sensa- 
tions without  any  lesion  of  the  part  or  of  the  nerve  supplying  it. 
It  is  important  in  examining  a  patient  for  painful  spots  that  no 
hint  be  given  of  the  object  of  the  examination,  lest  the  patient 
should  declare  that  any  spot  is  painful  over  which  greater  pres- 
sure is  made  or  to  which  his  attention  is  directed. 

Little  can  be  said  of  the  regulation  centers.  The  heat 
regulation,  cardiac  regulation,  vasomotor  centers,  etc.,  are  all 


SENILE  DEGENERATION  OF  THE  NERVES  151 

impaired  but  they  have  not  been  sufficiently  studied  to  make 
definite  statements  about  them. 

The  optic  nerve  and  retina  are  rarely  affected  but  there  may 
be  a  degenerative  albuminuric  retinitis  associated  with  a  gener- 
alized arteriosclerosis  and  chronic  interstitial  nephritis.  Optic 
neuritis  or  choked  disc  is  occasionally  found  under  the  same 
circumstances.  The  motor  nerves  of  the  eyeball  show  neither 
histological  nor  functional  changes.  There  is  often  a  slowness 
of  action  of  the  motor  muscles  which  may  be  due  to  muscle 
weakness  or  to  slowed  mental  impulse  or  response.  The  termi- 
nal ends  of  the  third  branch  of  the  trifacial  nerve  are  some- 
times subjected  to  pressure  in  the  bony  structure  of  the  lower 
maxilla  and  this  gives  rise  to  trifacial  neuralgia  (see  Trifacial 
Neuralgia).  It  is  supposed  that  neuralgia  of  the  second  branch 
is  due  to  arteriosclerosis  and  consequent  impaired  nutrition, 
although  this  form  of  neuralgia  often  appears  with  no  demon- 
strable lesion  in  either  nerve  or  blood-vessels.  The  lingual 
branch  shows  frequently  functional  impairment  in  diminished 
taste  without  histological  change. 

The  facial  nerve  is  rarely  if  ever  affected  as  the  direct  result 
of  senile  changes.  When  facial  paralysis  occurs,  it  either 
follows  cerebral  disease,  or  a  neuritis,  or  it  is  due  to  exposure, 
traumatism,  pressure  or  other  cause  not  connected  with  the 
senile  processes. 

The  glossopharyngeal  nerve  shows  in  the  aged  frequent  func- 
tional impairment  in  diminished  taste.  It  is,  however,  uncer- 
tain to  what  extent  degeneration  of  the  taste  buds  contribute 
to  this  result.  The  dysphagia  of  the  aged  is  due  to  lessened 
innervation  of  the  muscles  of  deglutition.  Various  functional 
perversions  in  parts  supplied  by  the  vagus  are  believed  to  be  due 
to  senile  degeneration  of  that  nerve.  To  this  cause  are  ascribed 
the  anomalies  in  the  rhythm  of  the  heart  and  of  respiration, 
pharyngeal  and  laryngeal  spasm,  aphonia,  and  most  gastric 
neuroses. 

The  spinal  accessory  nerve  shows  no  marked  functional 
change  in  old  age.  It  is  probable  that  the  weakening  of  the 
sternomastoid  and  trapezii  is  due  to  weakened  power  of  this 
nerve,  but  the  weakness  of  these  muscles  is  rarely  more  marked 
than  in  other  voluntary  muscles. 


152  PATHOLOGICAL    OLD   AGE 

The  hypoglossal  nerve  presents  no  symptoms  that  can  be 
ascribed  to  senile  degeneration. 

Senile  Degeneration  of  the  Organs  of  Special  Sense 

The  special  senses  are  weakened  or  perverted  in  old  age  but 
we  can  rarely  tell  with  any  degree  of  certainty  whether  the 
fault  lies  in  the  terminals,  nerves  or  cerebral  centers,  nor  whether 
the  cause  is  senile  involution  or  something  else.  In  many  cases 
no  histological  changes  can  be  found. 

Anosmia,  loss  of  smell,  may  be  due  to  obstruction  of  the 
passage  of  air  to  the  Schneiderian  membrane,  to  atrophy  or 
degeneration  of  this  membrane  or  of  the  olfactory  nerve  or 
bulb,  or  there  may  be  a  senile  dementia  with  diminished  power 
to  receive  or  interpret  sensory  impressions,  or  it  may  follow 
other  nasal  diseases  or  hysteria.  The  loss  of  smell  may  be  con- 
fined to  certain  odors  or  it  may  be  more  marked  at  certain  times, 
as  in  damp  weather.  The  sense  of  smell  is  usually  the  first  of 
the  special  senses  to  show  diminution  of  power,  the  impairment, 
however,  is  rarely  noticed  and  complete  anosmia  may  exist 
without  the  knowledge  of  the  individual. 

Parosmia  or  a  perverted  sense  of  smell  may  be  due  to  the 
same  causes  as  anosmia,  the  perversion  preceding  the  latter, 
or  it  may  be  due  to  mental  aberration,  hysteria  or  neurasthenia 
or  to  oral  or  nasal  disease  producing  a  fetid  odor.  It  is  often 
an  early  symptom  of  insanity. 

If  the  anosmia  is  due  to  senile  degeneration  nothing  can  be 
done  to  increase  the  sense  of  smell.  The  treatment  of  parosmia 
is  either  local  or  psychic  depending  upon  the  cause. 

Gustatory  anesthesia  generally  accompanies  anosmia  but  it 
rarely  proceeds  to  the  same  extent.  Taste  may  be  lost  for 
certain  substances,  or  only  the  temperature  sense  may  be  af- 
fected. There  is  usually  a  blunting  of  the  sense  of  taste  for 
alkaline,  sweet,  insipid  and  bitter  substances  but  not  for  salty, 
acid  or  acrid  ones.  The  impairment  may  be  due  to  a  change 
in  the  taste  corpuscles,  in  the  nerves  of  taste  or  in  the  cerebral 
centers.  Probably  all  three  are  responsible  for  the  functional 
impairment,  the  papillae  being  mainly  affected  through  the 
changes  in  the  covering  membrane  of  the  mouth  and  the  changes 
in  the  oral  secretions. 


ENILE   DEGENERATION   OF   ORGANS   OF   SPECIAL   SENSE  1 53 

Gustatory  paresthesia  is  rare  except  in  insanity  or  hysteria. 
Nothing  can  be  done  to  increase  the  sense  of  taste  due  to  senile 
degeneration. 

Presbyacusia,  diminished  sense  of  hearing,  due  to  age  is  fre- 
quent and  often  proceeds  to  complete  deafness.  The  apprecia- 
tion of  high  notes  is  generally  lost  and  low  notes  appear  higher. 
Tinnitus  and  other  abnormal  sounds  indicate  a  pathological 
condition ;  they  do  not  appear  in  the  ordinary  senile  impairment 
of  hearing.  They  are  generally  associated  with  cerebral  or 
local  arteriosclerosis.  Presbyacusia  occurs  earlier  in  the  cities 
than  in  the  country  and  when  found  in  city  dwellers  it  proceeds 
more  rapidly  and  is  more  frequently  subject  to  complications 
which  convert  the  normal  process  into  a  disease.  The  char- 
acter of  the  senile  process  is  unknown  as  both  atrophy  and 
thickening  of  the  drum  have  been  found  in  the  aged,  with  vari- 
ous degrees  of  deafness  and  without  functional  impairment, 
while  complete  deafness  may  exist  without  drum  or  nerve 
change,  or  any  other  known  cause.  It  is  believed  that  many 
cases  of  senile  deafness  are  of  cerebral  origin. 

Presbyacusia  is  sometimes  overcome  by  the  use  of  a  speak- 
ing tube,  mechanical  drum  or  other  appliance  which  will  cause 
more  direct  conduction  or  intensify  the  sound.  Drugs  and 
operative  procedure  are  useless. 

Presbyopia  or  difficulty  in  accommodation  to  near  objects 
is  the  ordinary  condition  of  the  senile  eye  and  is  due  to  sclerosis 
of  the  lens  with  probable  weakening  of  the  muscles  of  accommo- 
dation. The  contracted  pupils  and  slowed  reflexes  are  prob- 
ably due  to  changes  in  the  nervous  supply  and  in  the  muscles. 
No  distinctively  senile  changes  have  been  found  in  the  retina 
or  optic  nerve  and  in  those  who  have  not  abused  their  eyes  the 
sense  of  sight  remains  normally  acute.  Presbyopia  like  presby- 
acusia occurs  earlier  in  the  cities,  it  proceeds  faster  and  com- 
plications are  more  frequent.  Amblyopia  is  frequently  found 
in  the  aged;  it  is,  however,  not  a  senile  condition.  The  treat- 
ment for  presbyopia  is  appropriate  glasses.  Perversions  of 
sight  and  hearing  that  are  not  insane  illusions  may  occur  in 
cerebral  and  auditory  arteriosclerosis  but  they  do  not  occur  in 
the  ordinary  senile  degenerations  of  the  organs. 

Anesthesia  is  frequently  met  with  in  the  aged.  It  is  usually 
partial,  there  being  a  weakened  perception  of  touch,  pain  and 


154  PATHOLOGICAL   OLD    AGE 

temperature.  Complete  loss  of  sensibility  occurs  only  in  some 
forms  of  spinal  degeneration  and  is  then  associated  with  motor 
paralysis.  No  senile  anatomical  change  of  a  degenerative 
character  has  been  demonstrated  in  the  tactile  organs  and  it  is 
uncertain  whether  the  functional  impairment  is  due  to  slowed 
conduction,  weakened  cerebration  or  to  some  morphological 
change  which  has  hitherto  defied  recognition. 

Hyperesthesia  is  rare  in  old  age,  and  the  excessive  sensitive- 
ness from  which  the  aged  often  complain  is  generally  exaggerated 
through  the  fear  of  pain. 

Paresthesia  occurs  frequently  in  the  form  of  pruritus  and 
occasionally  as  formication. 

Senile  Pruritus 

Etiology. — This  is  one  of  the  most  frequent  and  most  annoy- 
ing of  the  ailments  of  old  age.  It  is  sometimes  due  to  psychic 
causes,  either  suggestion  or  mimicry.  Epidemic  senile  pruritus 
in  institutions  has  been  traced  to  mimicry,  one  patient  suffering 
from  a  pruritic  affection  and  others  seeing  that  patient  scratch, 
do  likewise.  The  mere  mention  of  an  itch-producing  cause, 
such  as  fleas,  will  sometimes  sufhce  to  arouse  the  sensation  of 
itching.  If  we  can  exclude  these  psychic  causes  as  well  as 
the  pruritic  dermatoses  presenting  surface  lesions,  parasites, 
also  the  diseases  which  are  usually  accompanied  by  pruritus, 
such  as  diabetes,  jaundice,  leukemia,  pseudoleukemia  and  neph- 
ritis, and  finally  all  local  causes  of  irritation,  such  as  woolen 
underwear,  acrid  bromidrosis,  etc,  we  necessarily  deal  then 
with  the  true  senile  pruritus  of  unknown  etiology  and  no  dis- 
coverable pathology.  Lesions  may  appear,  due  to  scratching, 
but  no  change  has  been  found  in  the  end  organs  to  account  for 
the  pruritus  itself. 

Symptoms. — The  itching  may  be  protracted,  intermittent 
or  ephemeral,  so  mild  as  to  be  barely  noticed  or  so  severe  as  to 
cause  intolerable  agony,  it  may  be  generalized,  scattered  over 
large  or  small  areas  or  localized.  When  localized  it  is  generally 
found  about  the  genitals  and  anus,  sometimes  about  the  legs, 
rarely  in  other  locations.  The  itching  is  usually  worse  at  night, 
in  damp  weather  and  after  excitement. 

Diagnosis. — In  dealing  with  senile  pruritus  we  must  first 
eliminate  other  forms  of  pruritus.     This  is  comparatively  easy 


SENILE    PRURITUS  1 55 

when  it  accompanies  internal  diseases  or  when  due  to  pruritic 
dermatoses  presenting  surface  lesions.  There  are  no  lesions  in 
senile  pruritus  unless  excoriation,  dermatitis  or  eczema  is  pro- 
duced by  scratching.  In  these  cases  the  irritation  long  preceded 
the  scratch  lesion. 

Pediculi  and  the  acarus  are  the  principal  dermal  parasites 
and  when  present  are  found  without  difficulty  in  the  locations 
which  they  infest. 

The  thread  worm,  oxyuris  vermicularis,  though  rare  in  the 
aged,  may  be  present  and  give  rise  to  an  intolerable  itching  about 
the  anus.  It  is  often  difficult  to  determine  the  cause  if  the  pru- 
ritus is  due  to  some  local  irritant.  The  most  frequent  source 
of  such  irritation  is  acid  or  acrid  perspiration,  sometimes  woolen 
or  flaxen  underwear  will  cause  it,  occasionally  handling  irritating 
substances  will  produce  it.  In  all  cases  in  which  there  is  a 
dermatitis  or  a  local  hyperemia  not  due  to  rubbing  we  can  ex- 
clude senile  pruritus.  It  is  sometimes  impossible  to  decide 
when  the  pruritus  is  due  to  psychic  causes.  In  one  institution 
where  several  sufferers  from  pruritus  charged  the  original  case 
with  spreading  phthiriasis  among  them,  it  was  necessary  to  iso- 
late all  patients  and  scrub  them,  although  none  had  pediculi. 

Treatment. — There  is  no  specific  treatment  for  senile  pruri- 
tus. The  same  measures  which  are  apparently  successful  in 
some  cases  are  detrimental  in  others,  while  in  some  cases  the 
itch  will  suddenly  disappear  after  all  treatment  had  been  dis- 
continued. The  only  drug  which  can  be  depended  upon  to  give 
temporary  relief  is  cocaine  in  a  2  per  cent,  ointment,  using  lano- 
line  or  sweet  butter  as  a  base.  Occasionally  a  single  application 
will  give  permanent  relief,  usually,  however,  the  itch  returns  in 
a  few  hours.  In  some  cases  hot  water,  in  some  again  cold  water 
applications  are  of  service.  Ice  and  freezing  mixtures  will  re- 
lieve the  itching  but  may  produce  frost  bites  followed  by  gan- 
grene. Weak  acid  solutions,  alkaline  solutions,  menthol,  thymol, 
irritants  like  capsicum  and  cantharides,  sedatives  like  bella- 
donna, stramonium  and  chloral,  have  all  been  recommended  and 
the  faradic  current  has  been  employed  with  benefit.  In  a  dis- 
ease of  this  character,  with  unknown  etiology  and  pathology, 
with  a  single  distressing  symptom,  our  efforts  must  be  directed 
to  the  relief  of  that  symptom  and  such  measures  can  be  used 
but  empirically. 


156  PATHOLOGICAL   OLD   AGE 

VARICOSE  VEINS 

Varix  is  the  most  frequent  affection  of  the  veins  in  old  age 
and  a  mild  type  becomes  physiological  with  advancing  years. 
As  the  senile  changes  in  the  heart  and  blood-vessels  proceed, 
the  venous  circulation  becomes  slower  the  veins  become  over- 
filled and  they  dilate. 

Etiology. — The  normal  varix  of  old  age  is  seen  in  the  super- 
ficial veins  of  the  hands  and  feet.  When  this  is  excessive  or 
due  to  other  causes  than  the  normal  changes  in  the  veins  and  the 
slackened  venous  circulation  it  is  pathological.  The  most  fre- 
quent site  of  this  form  of  varix  is  about  the  lower  limbs.  It  is 
found  mostly  in  women  who  have  had  children  and  is  then  car- 
ried over  from  maturity.  Among  men  it  is  generally  found  in 
those  who  stand  or  walk  much.  Arteriosclerosis  and  phlebo- 
sclerosis  is  generally  present  and  it  is  believed  that  in  almost 
every  case  there  is  an  obstruction  to  the  return  circulation  due 
to  tricuspid  stenosis.  (Hemorrhoidal  varix  will  be  treated 
under  Hemorrhoids.) 

Pathology. — The  vessel  becomes  longer  and  dilatation  occurs 
generally  just  above  the  valves.  The  vein  assumes  an  irregular 
or  wavy  line  with  a  single  globular  enlargement  or  there  may  be 
a  series  of  dilatations  giving  the  vessel  a  beady  appearance. 
In  some  cases  the  dilatation  extends  in  an  unbroken  line  for 
some  distance  along  the  vein.  The  coats  are  generally  hyper- 
trophied  except  at  the  dilated  portions  which  are  thin.  Cal- 
careous plaques  are  sometimes  found  in  the  walls  and  thrombi 
form  in  the  dilated  pouches. 

Symptoms. — The  veins  present  the  familiar  dark  blue,  wavy 
or  irregular  appearance  seen  upon  the  hands  of  the  aged.  Where 
the  varicosity  is  pronounced  the  vessel  appears  swollen  at  one 
place,  or  there  may  be  a  string  of  such  swellings,  or  the  swellings 
may  be  scattered  showing  that  several  vessels  are  involved. 
The  leg  feels  heavy  and  after  long  standing  a  hypostatic  edema 
sets  in  about  the  ankles. 

Varicose  veins  are  subject  to  many  complications.  The 
more  important  ones  are  pruritus,  eczema,  erysipelas,  thrombus 
rupture  and  ulcers.  Eczema  is  generally  the  result  of  scratching 
or  rubbing  where  there  is  an  intolerable  pruritus  and  the  same 
cause  may  be  followed  by  rupture,  ulcer  and  erysipelas. 


THROMBOSIS   AND   EMBOLISM  1 57 

Treatment. — Mild  varicosities  require  no  treatment.  When 
pronounced  the  treatment  is  either  radical  by  surgical  procedure 
or  palliative  by  means  of  bandages.  There  is  some  danger  in 
rubber  bandages,  as  they  may  compress  the  arteries  as  well  as 
the  dilated  veins  and  cause  impaired  nutrition  of  the  limb,  un- 
less they  are  applied  evenly  and  with  just  enough  tension  to 
compress  the  varix  without  compressing  the  limb.  A  close 
fitting  rubber  stocking  is  better.  For  the  intolerable  itching  a 
2  per  cent,  cocaine  lotion  or  ointment  can  be  used.  Sometimes 
ice  will  give  relief,  but  the  usual  antipruritic  remedies  are  gener- 
ally worthless.  If  the  pruritus  is  relieved,  the  eczema  can  usu- 
ally be  cured  by  the  application  of  stearate  of  zinc,  oxide  of 
zinc  or  bismuth  subnitrate.  As  long  as  the  pruritus  exists  no 
treatment  of  the  eczema  will  avail  as  it  will  be  impossible  to 
keep  the  patient  from  scratching. 

Hemorrhage  from  rupture  is  generally  controlled  without 
difficulty  by  compression  below  the  site  of  rupture.  Owing  to 
the  slowed  circulation  a  clot  will  be  speedily  formed  and  if  care 
is  taken  to  prevent  infection  repair  will  take  place.  (Erysipelas 
is  treated  under  the  Infectious  Diseases  and  Ulcer  under  Diseases 
of  the  Skin.) 

SECONDARY  SENILE  DISEASES 

The  diseases  of  the  second  group  are  always  secondary  al- 
though the  primary  condition  may  be  so  obscure  as  to  be 
unknown  or  unnoticed  before  the  secondary  disease  appears. 
Typical  examples  of  this  group  are  apoplexy,  senile  gangrene, 
and  angina  pectoris. 

THROMBOSIS  AND  EMBOLISM 

These  occur  rather  frequently  in  the  aged.  Though  usually 
described  together  they  differ  so  greatly  in  their  etiology,  path- 
ology, symptoms  and  prognosis  that  they  will  be  considered 
separately. 

THROMBOSIS 

Etiology. — Thrombosis  may  be  due  to  damage  to  the  lining 
membrane  of  the  vessel,  to  slowed  circulation,  or  to  a  change 
in  the  character  of  the  blood  whereby  its  coagulability  is  in- 
creased.    In  old  age,  all  three  causes  usually  prevail,  thus  ac- 


158  PATHOLOGICAL    OLD    AGE 

counting  for  its  frequency  at  that  period  of  life.  It  may  occur 
in  either  arteries  or  veins,  the  latter  being  more  often  affected, 
the  circulation  being  slower  there;  especially  is  this  the  case  in 
the  lower  extremities  and  in  the  brain.  The  damage  to  the 
vessel  is  usually  due  to  an  arteriosclerosis  or  fatty  degeneration, 
the  site  of  the  lesion  being  the  focus  for  the  deposit  of  the  agglu- 
tinated blood  cells  which  form  the  primary  thrombus.  Vari- 
cose veins  are  frequently  the  seat  of  thrombosis.  Other  causes 
less  prevalent  in  the  aged  are  inflammation,  toxemia,  dilatation 
of  the  vessel  or  of  the  heart.  Some  of  the  infectious  diseases 
cause  thrombosis,  either  by  direct  effect  of  the  toxemia  upon 
the  lining  membrane  of  the  vessel  or  by  changing  the  character 
of  the  blood  by  which  its  viscosity  is  increased. 

Slowed  current  may  be  due  to  cardiac  dilatation  or  weakness, 
or  to  dilatation  of  the  vessels  as  in  varicose  veins.  The  senile 
changes  in  the  blood  are  unknown.  Its  viscosity  is  increased 
and  its  coagulability  is  consequently  greater  than  in  maturity 
but  it  is  uncertain  whether  there  are  other  changes  also  which 
tend  to  cause  agglutination  of  the  cells  and  adhesion  of  the 
blood  plates  to  the  walls  of  the  vessel.  Traumatic  causes,  as 
compression  of  a  vessel,  may  produce  thrombosis  and  thrombi 
are  frequently  found  in  the  heart,  either  as  small  vegetations 
or  as  adherent  coagula.  These  are  probably  formed  shortly 
before  death. 

Pathology. — Whether  occurring  in  an  artery  or  in  a  vein  the 
pathological  process  is  the  same.  In  the  normal  flow  the  red 
cells  and  blood  plates  keep  to  the  center  of  the  stream  while 
the  white  cells  travel  along  the  wall  of  the  vessel.  When  the 
circulation  is  slowed  the  plates  leave  the  center  and  accompany 
the  leucocytes.  They  will  either  adhere  to  the  healthy  endo- 
thelium or,  finding  a  spot  which  is  broken  down,  this  spot  becomes 
then  the  focus  for  the  thrombus.  The  fibrin  element  parting 
from  the  plasma,  the  plates  and  the  fibrin  form  the  primary 
layer  or  primary  thrombus  upon  which  layer  after  layer  of 
plates  and  fibrin  are  deposited.  The  caliber  of  the  vessel  is 
diminished  and  it  may  be  entirely  obliterated.  This  usually 
proceeds  slowly  and  in  many  cases  collateral  circulation  is  fully 
established  before  complete  obliteration  takes  place.  When 
occurring  in  a  terminal  artery,  the  tissue  supplied  from  the 
vessel  beyond  the  occlusion  is  deprived  of  nutrition  and  in- 


THROMBOSIS  1 59 

f arction  results.  In  some  cases  the  thrombic  formation  proceeds 
so  rapidly  that  complete  occlusion  occurs  before  any  compen- 
satory collateral  circulation  is  established  and  gangrene  results. 
This  occurs  most  frequently  in  thrombosis  following  infectious 
diseases  and  is  rare  in  the  aged.  In  venous  thrombus  there  is 
passive  congestion  and  edema  of  the  part  below  the  occlusion. 
The  thrombic  deposits  are  sometimes  removed  by  a  process  of 
softening,  while  sometimes  they  become  organized  and  form 
part  of  the  vascular  wall.  In  some  cases  particles  are  torn  off 
and  are  carried  in  the  circulation  as  emboli. 

Symptoms. — The  symptoms  of  thrombosis  depend  upon  the 
location  and  rapidity  of  formation. 

The  most  frequent  location  of  thrombosis  in  the  aged  is  in 
one  of  the  cerebral  vessels.  (The  symptoms  are  described 
under  Cerebral  Softening  while  cardiac  thrombosis  will  be  de- 
scribed separately.) 

Venous  thrombus  occurs  most  frequently  in  the  veins  of  the 
lower  extremities,  occasionally  in  the  cerebral  sinuses  and  veins, 
rarely  in  other  veins.  In  the  aged  the  most  frequent  cause  of 
venous  thrombus  is  phlebosclerosis  with  slowed  circulation, 
rarely  a  phlebitis.  In  the  lower  limbs  the  usual  location  is  in 
the  dilated  portions  of  a  varicose  vein.  Sometimes  the  deposits 
can  be  felt  as  hard  lumps  which  cause  pain  when  pressed  upon. 
There  is  generally  pain  and  edema  upon  standing,  both  sub- 
siding when  the  limb  is  in  a  horizontal  position.  If  there  is  a 
phlebitis  the  pain  is  constant  and  severe,  the  edema  is  exten- 
sive, there  is  fever  and  other  symptoms  of  inflammation  and 
the  thrombosis  progresses  rapidly.  Phlebitis  is,  however,  very 
rare  in  old  age  and  when  it  does  occur  it  is  almost  always  due 
to  traumatism.  The  principal  danger  from  venous  thrombus 
lies  in  the  detachment  of  particles  which  are  carried  to  the 
heart  and  then  to  the  lungs  as  emboli. 

Sinus  thrombosis  is  rare  in  the  aged,  and  when  occurring  it 
is  almost  always  secondary  to  an  injury,  inflammation  or  other 
pathological  condition  in  or  about  the  skull.  Primary  throm- 
bosis of  the  longitudinal  sinus  has  been  found  upon  autopsy 
which  gave  no  symptoms  during  life  and  for  which  no  cause 
could  be  found.  There  are  no  clearly  defined  symptoms  point- 
ing to  this  disease.  There  is  usually  headache,  dizziness,  mental 
depression;  there  may  be  convulsions,  hemiplegia,  and  other 


l6o  PATHOLOGICAL   OLD   AGE 

cerebral  symptoms,  but  all  these  may  be  due  to  the  primary 
disease  or  may  be  associated  with  other  conditions.  Fulness 
of  the  veins  of  the  face  and  head  and  local  edema  are  fairly 
indicative  of  sinus  thrombosis  but  they  are  not  always  present. 
In  many  cases  the  disease  is  of  septic  origin  and  then  there  will 
be  a  jugular  phlebitis  with  symptoms  of  pyemia. 

Treatment. — (The  treatment  of  gangrene,  cerebral  softening 
and  cardiac  thrombus  will  be  given  under  those  heads.)  The 
treatment  of  sinus  thrombus  is  surgical  and  must  be  directed 
to  the  causative  condition.  In  the  venous  thrombosis  of  the 
lower  extremity,  if  due  to  phlebitis,  the  latter  must  be  treated. 
Absolute  rest,  the  limb  being  rendered  immobile  by  splints,  is 
imperative.  Local  applications  of  hot  water  or  hot  lead  water 
should  be  made.  If  there  is  an  underlying  septic  condition 
that  must  be  treated,  and  if  these  measures  fail  surgical  inter- 
ference may  be  necessary.  If  the  thrombus  forms  in  a  varicose 
vein,  rest  and  the  application  of  tincture  of  iodine  or  iodide  of 
potassium  ointment,  with  strapping  of  the  limb,  may  effect  a 
cure. 

Cardiac  Thrombosis 

At  almost  every  autopsy  a  clot  is  found  in  the  heart.  It  is 
probable  that  most  clots  are  formed  shortly  before  death  when 
blood  changes  favor  coagulation  and  the  slow  current  permits 
their  adhesion  to  the  walls  of  the  cavities.  In  many  cases, 
however,  the  clots  are  evidently  of  long  standing,  firm  and  closely 
adherent  to  the  walls. 

Etiology. — The  causes  of  cardiac  thrombi  are  obstruction 
to  the  passage  of  blood  through  the  heart  as  in  valvular  defects, 
slowing  of  the  current  through  dilatation  or  atonicity  of  the 
myocardium,  change  in  the  character  of  the  blood  whereby  its 
coagulability  is  increased  as  in  infectious  diseases,  nephritis,  dia- 
betes, etc.,  and  roughening  of  the  endocardial  surface.  Small, 
firmly  adherent,  slowly  developing  thrombi,  called  vegetations, 
occur  frequently  after  rheumatism  and  in  the  various  valvular 
degenerations. 

Pathology. — The  vegetations  are  usually  fibrinous  adhesions 
to  the  valves  or  cordae  tendinae.  They  are  of  the  same  con- 
sistency as  the  adjoining  tissue,  lighter  in  color  with  irregular 


EMBOLISM  l6l 

edges.  Larger  and  more  recent  thrombi  may  reach  the  size  of 
a  walnut  and  may  be  found  in  any  cavity.  They  may  be  firm 
but  are  usually  soft  and  jelly-like,  while  in  diseases  running  a 
rapidly  fatal  course  they  are  very  soft.  Older  thrombi  consist 
of  exsanguinated  fibrin,  are  light  in  color  and  are  usually  closely 
adherent  to  the  endocardium. 

Symptoms. — The  vegetations  rarely  give  any  pronounced 
symptoms  except  where  they  extend  beyond  the  edges  of  valves 
and  thus  produce  stenosis.  The  symptoms  then  are  the  symp- 
toms of  valvular  stenosis.  If  a  thrombus  forms  rapidly  and  is 
of  large  size  it  may  cause  a  speedy  fatal  end  by  complete  obstruc- 
tion of  the  cardiac  circulation.  If  smaller  or  developing  more 
slowly  there  is  dyspnea,  cyanosis,  partial  syncope,  irregular 
and  weak  heart  action,  hurried  respiration,  restlessness  and 
anxiety,  later  cerebral  symptoms,  pulmonary  edema  and  finally 
coma.  In  some  cases  death  occurs  in  a  few  hours.  A  small 
thrombus  may  give  less  severe  symptoms  but  the  condition  is 
always  grave  and  generally  fatal. 

Treatment. — There  is  no  known  treatment  for  this  condi- 
tion. The  alkaline  carbonates  are  supposed  to  have  the  power 
to  prevent  coagulation  but  neither  these  nor  the  iodide  of 
potassium  relieve  the  symptoms  or  prevent  death  when  a  large 
thrombus  has  formed.  In  milder  cases  rest  and  small  doses  of 
digitalis  and  opium  may  be  tried. 

EMBOLISM 

Embolism  occurs  more  frequently  in  the  aged  than  in  earlier 
life,  as  some  of  the  principal  sources  of  the  embolus  are  mainly 
found  in  the  aged.  It  may  be,  moreover,  directly  responsible 
for  several  senile  pathological  conditions,  such  as  cerebral 
softening,  senile  gangrene,  etc. 

Etiology. — Embolism  is  a  secondary  disease,  the  plug  itself 
being  a  pathological  product  of  some  other  disease.  It  may  be 
a  fragment  of  a  blood  clot  detached  from  a  thrombus,  a  particle 
of  calcareous  or  other  matter  from  an  atheromatous  plate, 
vegetation  from  the  endocardium,  a  piece  of  neoplasm,  a  mass 
of  bacteria  or  a  mass  of  pigment.  It  may  be  a  fat  embolus,  or 
hyaline  matter  or  any  other  substance  that  has  made  its  way 
into  the  circulation.  The  plug  is  carried  in  the  circulation,  and 
if  coming  from  a  vein  or  the  right  side  of  the  heart,  it  lodges  in 


ii 


1 62  PATHOLOGICAL   OLD   AGE 

the  pulmonary  artery  or  in  one  of  the  branches ;  if  coming  from 
the  left  side  of  the  heart  or  from  an  arterial  source  it  is  carried 
to  some  smaller  vessel,  which  it  blocks.  Thrombic  or  athero- 
matous fragments  or  vegetations  may  become  detached  when 
the  heart  action  is  suddenly  increased  by  exercise,  drugs  or 
a  sthenic  inflammation  and  the  blood  current  is  sent  through 
the  diseased  vessel  with  greater  force. 

Pathology. — Plugging  of  an  artery  or  arteriole  causes  anemia 
and  degeneration  or  gangrene  of  the  tissues  supplied  by  the 
part  beyond  the  plug,  unless  anastomosis  and  collateral  circula- 
tion is  speedily  established.  In  embolism  of  smaller  vessels 
and  arterioles,  except  in  terminal  arteries,  anastomosis  generally 
occurs.  If  a  larger  vessel  is  blocked  or  when  it  is  a  terminal 
vessel,  infarction,  degeneration  or  gangrene  follows,  or  it  may 
cause  complete  functional  arrest  and  death  as  when  the  pul- 
monary artery,  coronary  artery  or  one  of  the  larger  cerebral 
vessels  is  blocked.  In  some  cases  the  lumen  is  not  completely 
plugged  by  the  embolus.  Fibrin  is  then  deposited  upon  it 
and  a  thrombus  is  formed  which  may  completely  block  the  ves- 
sel. If  this  occurs  in  a  larger  vessel  the  part  beyond  the  plug 
is  not  immediately  cut  off  from  nutrition  and  collateral  circula- 
tion may  be  established  before  the  lumen  is  closed  entirely. 

Symptoms. — Pulmonary  embolism  occurs  when  the  pulmo- 
nary artery  or  a  branch  is  blocked.  The  embolus  is  either 
carried  from  a  vien,  being  a  detached  portion  of  a  thrombus, 
or  it  originates  in  a  vegetation  of  the  right  heart.  In  old  age 
when  the  venous  circulation  is  normally  weak,  degeneration 
of  the  endocardium  of  the  right  heart  leads  to  the  formation  of  a 
thrombus  which  may  become  dislodged  by  a  powerful  cardiac 
contraction  and  carried  to  the  pulmonary  artery  or  may  oc- 
clude one  of  its  branches.  If  a  main  branch  is  blocked  there 
will  be  instant  collapse  and  death.  If  a  small  vessel  is  closed 
up  a  hemorrhagic  infarction  will  result.  This  begins  with  a 
sudden,  severe  pain,  dyspnea,  a  feeling  of  oppression  and  anx- 
iety, sometimes  a  chill.  The  heart  is  weak,  there  is  usually  cya- 
nosis and  blood-streaked  expectoration  and  there  may  be  small 
blood  clots  in  the  sputum.  The  severity  of  the  symptoms  varies 
with  the  extent  of  pulmonary  involvement,  a  minute  infarction 
giving  no  pronounced  symptoms  except  perhaps  the  expec- 
toration of  small  blood  clots.     Dark  scanty  hemoptysis  is  the 


Adams-Stokes  disease,  showing  the  patient  just  recovering  from  a  syncopal  attack,  with 
rapid  pulsation  visible  in  the  depression  above  the  clavicle.  From  "Heart  Disease  and  Blood 
Pressure"  by  L.  F.  Bishop,  M.  D.     (Funk  &  Wagnalls,  New  York.) 


Seconds 


Tracing  of  the  jugular  and  radial  pulses  during  eight  seconds. 
(From  "Heart  Disease  and  Blood  Pressure"  by  L.  F.  Bishop,  M.  D. 
(Funk  &  Wagnalls,  Xew  York.) 


EMBOLISM  163 

pathognomonic  sign  of  pulmonary  infarction  (Loomis).  The 
condition  is  serious  even  with  a  small  infarction.  Embolism  in 
the  brain  produces  cerebral  softening  which  will  be  described 
separately. 

Portal  embolism  may  occur  from  embolic  matter  brought  from 
the  stomach,  intestines,  spleen  or  pancreas.  The  free  anasto- 
mosis of  the  portal  and  hepatic  systems  whereby  rapid  collateral 
circulation  is  established  prevents  the  formations  of  infarctions. 
Portal  embolism  gives  no  symptoms  unless  there  is  complete 
occlusion,  when  the  symptoms  are  the  same  as  in  the  hepatic 
obstruction  of  cirrhosis  of  the  liver. 

Renal  embolism  produces  renal  hemorrhagic  infarction.  The 
embolus  generally  comes  from  a  fragment  of  endocardial  or 
valvular  vegetation  which  was  torn  away  by  some  powerful 
cardiac  contraction  as  after  exercise,  or  from  the  loosening  of 
some  atheromatous  matter.  The  symptoms  are  fever,  an  ache 
or  pain  in  the  the  region  of  kidneys  coming  on  suddenly  and 
persisting,  blood  in  the  urine,  and  symptoms  of  cardiac  disease 
or  arteriosclerosis. 

Femoral  embolism  is  rare  in  old  age.  When  it  does  occur 
there  is  a  sudden  severe  pain,  the  limb  is  blanched  and  numb, 
followed  by  complete  loss  of  sensation  and  motion.  If  the 
occlusion  is  complete  and  collateral  circulation  is  not  rapidly 
established  gangrene  sets  in,  beginning  in  the  foot  and  extending 
upward.  Partial  occlusion  or  incomplete  collateral  circulation 
causing  imperfect  nutrition  of  the  part  beyond,  will  result  in 
atrophy  of  the  limb  with  impaired  motion  and  sensation.  Em- 
bolism of  a  branch  of  the  femoral  or  in  another  vesssel  of  the 
lower  extremity  produces  the  same  result,  the  extent  depending 
upon  the  extent  of  the  occlusion,  the  rapidity  and  extent  of  the 
collateral  circulation  and  the  amount  of  tissue  which  has  been 
deprived  of  nutrition. 

Air  Embolus. — This  occurs  when  air  enters  a  vein.  If  it  is  a 
minute  globule  it  produces  a  momentary  arrhythmia  on  reaching 
the  heart.  A  larger  amount  of  air  will  produce  a  spasm  of  the 
heart  and  may  cause  fatal  collapse. 

Mountain  Sickness. — The  rapid  ascent  of  high  altitudes  is 
liable  to  produce  cardiac  thrombosis  and  pulmonary  embolism 
in  aged  persons.  The  attack  may  occur  several  days  after  the 
descent  and  is  fatal. 


164  PATHOLOGICAL    OLD    AGE 

Treatment. — A  large  pulmonary  embolus  is  rapidly  fatal. 
If  it  is  a  small  embolus  causing  an  infarction,  our  main  reliance 
is  in  absolute  rest  and  the  treatment  of  symptoms  as  they  arise. 
Cardiac  stimulants  are  contraindicated  as  they  may  dislodge 
further  emboli.  If  the  circulation  is  weak,  hot  water  should  be 
applied  to  the  feet,  and  dry  cups  and  sinapisms  to  the  back  and 
chest.  If  there  is  great  dyspnea  morphine  and  atropia  should 
be  used.  When  the  acute  symptoms  subside  iodide  of  potassium 
should  be  given  to  promote  absorption. 

No  treatment  is  required  in  a  portal  embolism.  If  complete 
occlusion  occurs  it  should  be  treated  the  same  as  cirrhosis  of  the 
liver. 

In  renal  embolus,  tannic  acid  in  5 -grain  doses  will  control 
the  hemorrhage,  but  ergot,  which  is  of  service  in  this  disease  in 
earlier  life,  is  inadmissible  if  there  is  arteriosclerosis.  Diuretics 
are  contraindicated.  Iodide  of  potassium  may  be  used  in  small 
doses  to  secure  absorption  and  elimination  of  the  degenerated 
tissue. 

In  embolism  of  the  femoral  or  other  artery  of  the  lower  ex- 
tremity, active  local  hyperemia  should  be  produced  and  main- 
tained to  stimulate  collateral  circulation.  If  this  fails  and  gan- 
grene sets  in  surgical  interference  will  alone  avail  to  save  the 
limb  or  the  patient. 

SENILE  GANGRENE 

Senile  or  atheromatous  gangrene  is  a  dry  gangrene  due  to 
tissue  starvation  through  an  obliterating  arteriosclerosis.  The 
dry  gangrene  following  embolism,  thrombus,  traumatism  or 
chilling  of  the  surface,  does  not  differ  in  pathology  or  symptoms 
from  the  other  and  when  occurring  in  the  aged  is  included  in  the 
term  of  senile  gangrene.  Moist  or  septic  gangrene  which  is  due 
to  infection  or  to  diabetes  is  not  strictly  a  senile  gangrene  but 
will  be  included  here  for  the  sake  of  continuity  of  description. 

Etiology. — The  cause  of  senile  gangrene  is  the  closure  or 
obliteration  of  a  vessel  where  collateral  circulation  is  not  rapidly 
established.  This  may  occur  as  the  result  of  an  arteriosclerosis 
or  embolus,  less  frequently  a  thrombus.  It  may  also  occur  when 
the  surface  has  been  chilled  and  the  circulation  is  poor,  the  ves- 
sels contracting  and  the  circulation  ceasing  in  the  part  involved. 


Nodule 


Photograph  of  Heart  in  a  case  of  Adams-Stokes  disease — showing  Calcareous 
nodules  (center  of  picture  just  below  the  aortic  valves)  in  the  region  of  the  bundle 
of  His.  (From  " Heart  Disease  and  Blood  Pressure"  by  L.  F.  Bishop,  M  D. 
(Funk  &  Wagnall's,  New  York.) 


SENILE   GANGRENE  1 65 

Traumatism  may  cause  gangrene  through  injury  to  a  vessel  or 
through  pressure  upon  a  part,  as  occurs  in  bedsores.  In  this 
case  there  may  be  either  destruction  of  the  part  through  direct 
compression  or  through  the  compression  of  the  nutrient  vessels. 
In  many  cases  of  senile  gangrene  there  is  a  history  of  gout, 
rheumatism,  syphilis,  alcoholism,  or  infectious  disease,  all  causes 
for  chronic  endarteritis  with  consequent  thrombosis  or  embolism. 
Some  are  the  terminal  stage  of  Raynaud's  disease.  Moist 
gangrene  may  follow  an  infectious  disease,  infection  of  a  surface 
lesion  or  some  disease  like  diabetes,  nephritis,  or  cerebral  disease 
which  diminishes  the  resistance  to  infection. 

Senile  gangrene  occurs  most  frequently  in  one  of  the  lower 
extremities,  generally  in  a  foot  or  toes,  occasionally  in  an  upper 
extremity,  rarely  in  two  membranes  at  the  same  time  or  in  other 
parts  of  the  body,  except  when  frozen  or  injured. 

Symptoms. — The  earliest  symptoms  of  senile  gangrene  is  a 
tingling  or  feeling  of  numbness  in  the  part,  the  part  becomes 
pale  and  cold  and  later  it  is  livid.  If  occurring  in  the  foot,  the 
latter  feels  heavy  and  cold  and  its  sensibility  is  diminished. 
After  a  time  a  brownish  or  purplish  spot  or  patch  appears,  which 
increases  in  extent  and  becomes  darker  until  it  is  almost  black. 
The  skin  over  this  area  is  dry,  hard,  and  leathery,  and  may  ex- 
foliate. The  area  involved  is  insensible  to  pressure  or  punctures, 
sensation  and  motion  being  completely  lost.  The  tissues  be- 
come mummified.  The  destruction  proceeds  until  all  the  tissues 
in  which  the  blood-supply  was  cut  off  are  involved.  In  most 
cases  there  is  a  line  of  demarkation  where  the  gangrene  stops 
and  the  part  destroyed  falls  off.  In  some  cases  there  is  no  line 
of  demarkation  and  the  destruction  of  tissue  proceeds  in  all 
directions.  This  occurs  more  frequently  in  moist  gangrene.  In 
this  form  the  tissues  become  soft  and  pulpy  and  putrefy  with 
the  formation  of  pus.  There  is  the  odor  of  decomposition  and 
the  tissue  resembles  the  slough  of  an  ulcer.  There  is  usually 
some  pain  in  the  beginning  but  this  soon  gives  way  to  tingling 
numbness  and  insensibility.  In  septic  gangrene  there  are  the 
usual  symptoms  of  septicemia,  rigors,  irregular  fever,  perspi- 
ration, rapid  pulse,  some  stupor  and  typhoid  symptoms. 

Senile  gangrene  due  to  thrombus  or  arteriosclerosis  proceeds 
slowly,  the  paling  and  tingling  being  so  slight  at  the  beginning 
as  to  barely  attract  attention,  gradually  becoming  more  intense. 


1 66  PATHOLOGICAL    OLD   AGE 

The  gangrene  due  to  embolus  generally  begins  with  a  sharp 
pain  followed  by  tingling  or  numbness,  and  the  disease  pro- 
gresses rapidly.  The  prognosis  is  good  as  to  life  if  a  line  of  de- 
markation  is  formed  and  the  area  involved  is  small.  Aged  per- 
sons have  recovered  after  amputation  at  the  hip-joint.  As  for 
the  part  involved  the  prognosis  is  unfavorable.  It  is  some- 
times possible  to  arrest  the  disease  with  but  slight  loss  of  tissue ; 
even  complete  recovery  has  been  effected.  Moist  gangrene 
proceeds  rapidly,  there  is  no  line  of  demarkation  and  it  is  almost 
always  fatal. 

Treatment. — The  treatment  depends  upon  the  cause  and 
the  stage  of  the  disease.  Tissue  that  has  already  become  gan- 
grenous must  be  removed.  If  septic  symptoms  appear  rapid 
excision  or  amputation  is  imperative.  Temporizing  is  fatal  in 
such  cases.  In  the  early  stage  of  dry  gangrene  it  is  sometimes 
possible  to  bring  about  rapid  collateral  circulation  by  applying 
hot  water  constantly  to  the  part.  It  should  not  be  raised. 
In  the  gangrene  following  arteriosclerosis,  iodide  of  potassium 
should  be  given  in  5 -grain  doses  every  four  hours  until  the 
physiological  effects  of  iodism  appear,  in  order  to  produce 
lessened  viscosity  of  the  blood. 

If  it  is  a  frozen  part  heat  should  be  applied  gradually  and 
the  tissue  massaged.  When  operation  becomes  necessary,  if 
there  is  no  line  of  demarkation,  amputation  must  be  performed 
at  the  joint  above  the  lesion. 

CARDIAC  NEUROSES 

These  are  functional  disorders  involving  temporary  or  per- 
manent change  in  force,  frequency  or  rhythm  of  the  heart. 
These  anomalies  are  in  some  instances  symptoms  of  organic 
disease  of  the  heart  itself  or  of  the  coronaries,  or  of  gastric 
or  cerebral  disturbance,  fever,  toxemia,  pain,  etc.;  in  some 
cases  they  are  due  to  non-pathological  causes,  such  as  meno- 
pause, high  altitudes,  hot  baths,  exercise,  excitement  or  exhaus- 
tion, the  use  of  tea,  coffee,  tobacco,  etc.  They  may  also  be 
due  to  senile  changes  in  the  nervous  regulation  of  the  heart 
either  in  the  vagus  or  in  the  intrinsic  ganglia,  or  to  some  altera- 
tion in  the  muscular  structure.  The  heart  beats  should  be 
counted  and  their  character  determined  at  the  heart  and  not 


PALPITATION  167 

at  the  radial  pulse,  as  radial  arteriosclerosis  may  alter  the 
character  of  the  latter,  or  beats  may  be  lost  between  the  heart 
and  wrist,  or  the  ventricular  contraction  may  be  so  weak 
that  the  impulse  is  not  carried  with  sufficient  force  to  distant 
vessels  to  give  a  palpable  pulse.  The  pulse,  moreover,  gives 
no  indication  of  the  condition  of  the  auricles. 

When  these  changes  in  the  force,  frequency  or  rhythm  of 
the  heart  are  due  to  diseases  presenting  anatomical  lesions, 
as  in  valvular  disease,  or  are  symptoms  of  clearly  denned  path- 
ological conditions,  such  as  fever,  they  cannot  be  considered 
as  neuroses.  It  is,  moreover,  probable  that  every  neurosis  is 
dependent  upon  some  temporary  or  permanent  change  in  the 
structure  or  character  of  the  tissue,  the  function  of  which 
is  impaired.  So  long  as  we  have  not  determined  what  that 
change  is,  we  class  such  functional  disturbance  as  a  neurosis  or 
psychosis. 

Palpitation 

This  is  an  alteration  in  the  force,  frequency  or  rhythm 
of  the  heart  which  becomes  noticeable  to  the  individual. 

Etiology. — When  permanent,  it  is  a  symptom  of  organic 
heart  disease,  exophthalmic  goiter,  or  a  continuance  of  a  non- 
pathological  cause,  as  excessive  smoking,  tea,  coffee,  alcohol, 
sexual  indulgence,  etc. 

Temporary  palpitation  of  the  heart  may  be  due  to  any  of 
the  non-pathological  causes  mentioned,  to  other  neuroses,  to 
upward  pressure  upon  the  diaphragm  from  a  distended  stomach, 
irritation  of  the  nervous  system,  strong  emotions,  even  pleas- 
urable anticipation,  or  abnormal  condition  of  the  blood  as  in 
anemia,  uremia,  or  other  toxemias.  It  also  occurs  in  uterine 
and  ovarian  disorders.     In  some  cases  no  cause  can  be  found. 

Symptoms. — The  pathognomonic  symptom  is  a  more  or  less 
violent  thumping,  beating  or  fluttering  of  the  heart  perceptible 
to  the  patient.  When  due  to  organic  heart  disease  there  is 
generally,  arrhythmia  with  the  other  symptoms  of  the  under- 
lying condition.  In  exophthalmic  goiter  there  are  the  symp- 
toms of  that  disease.  When  due  to  other  causes  there  is  gener- 
ally a  tachycardia  lasting  as  long  as  the  palpitation  lasts.  Other 
symptoms  depend  upon  the  cause.     If  due  to  gas  distending 


1 68  PATHOLOGICAL   OLD    AGE 

the  stomach  and  pressing  upward  upon  the  diaphragm,  there 
will  be  eructations  with  relief  from  the  palpitation.  In  anemia 
there  will  be  an  anemic  bruit  at  the  base  of  the  heart.  Shock 
and  fright  will  leave  the  face  pale;  in  excitement  the  face  will 
be  flushed.  There  may  be  nervous  or  hysterical  manifestations, 
dyspnea,  etc.,  attributable  to  the  cause  of  the  palpitation.  If 
there  is  no  organic  lesion,  the  physical  signs  may  be  negative, 
perhaps  nothing  more  than  increased  frequency  or  force  of 
heart  action. 

Treatment. — The  treatment  of  palpitation  of  the  heart 
depends  upon  its  cause.  If  it  is  distressing  and  the  cause 
cannot  be  removed,  an  ice  bag  over  the  heart  and  15  grains  of 
bromide  of  sodium  will  often  give  relief.  If  there  is  consider- 
able mental  agitation,  5  to  10  grains  of  veronal  and  5  grains  of 
monobromated  camphor  should  be  given.  If  these  do  not 
give  relief  a  hypodermic  injection  of  |  grain  of  morphine  and 
xxo  grain  atropia  should  be  used.  In  all  cases  the  cause  must 
be  removed  if  possible.  In  many  senile  cases  the  cause  can 
be  traced  to  a  distended  stomach  and  rapidly  acting  cathartics 
are  required.  In  high  altitudes  the  patient  should  practice  rapid 
and  deep  breathing.  Drugs  are  rarely  required  except  during 
a  severe  attack. 

Bradycardia 

A  pulse  rate  of  50  to  60  a  minute  is  natural  to  many  aged 
individuals  and  is  generally  due  to  increased  arterial  tension, 
the  heart  acting  slower  but  more  powerfully  to  overcome  the 
increased  resistance  of  the  vessels. 

Etiology. — The  most  frequent  cause  of  bradycardia  in  the 
aged  has  just  been  stated.  It  may  also  occur  in  organic  heart 
disease,  more  especially  in  cardiac  degenerations,  irritation  of 
the  vagus,  in  various  toxemias,  in  convalescence  from  exhaust- 
ing diseases,  in  chronic  diseases,  in  exhaustion,  inanition,  sun- 
stroke, syncope,  meningitis,  apoplexy,  etc.  As  a  pure  neurosis 
it  occurs  with  other  neuroses  and  some  psychoses,  especially 
with  neurasthenia,  melancholia,  hysteria,  epilepsy  and  paresis. 
(Heart  block,  in  which  bradycardia  is  a  prominent  symptom 
will  be  described  separately.) 

Symptoms. — The  pathognomonic  symptom  is  a  diminished 


I    *-**■■ 


»•    »'-■»■'■*    ■    .    ■    * 


'    *>»«»»».>. 


■    I    I    1    I   *  A 


B 


i-*-^-*-*-*— *—*—*—*—*-*— *—^-^-^-—-^ \  \_t 

A.  Complete  Arrhythmia.     Fibrillation  of  the  Auricle      (Courtesy  of  L.  F.  Bishop,  M. 
D.,  New  York.)     B.  Same  case  ten  days  later  under  influence  of  Digitalis. 


TACHYCARDIA  1 69 

frequency  of  the  action  of  the  heart.  The  beat  should  be 
counted  at  the  heart  and  never  at  the  radial  pulse.  Other 
symptoms  belong  to  the  causative  condition. 

If  persistent  it  is  a  symptom  of  organic  heart  disease,  irrita- 
tion of  the  vagus,  exhaustion,  convalescence,  etc.  Temporary 
bradycardia  may  be  due  to  syncope,  pain,  toxemia  and  mental 
depression. 

Treatment. — The  treatment  depends  upon  the  cause.  It 
is  rarely  necessary  to  institute  treatment  for  the  bradycardia 
itself,  as  it  gives  no  distressing  symptoms  and  it  will  disappear 
or  improve  with  the  arrest  or  improvement  of  the  cause. 

Tachycardia 

Rapid  heart  action  is  sometimes  natural  to  the  individual 
and  cases  have  been  reported  in  which  there  was  a  heart  beat 
of  115  to  130  a  minute  without  distress  and  without  any  other 
symptom  or  sign  pointing  to  a  pathological  condition. 

Etiology. — In  the  aged  tachycardia  is  frequently  associated 
with  coronary  sclerosis.  All  the  causes  that  may  give  rise  to 
palpitation  may  produce  rapid  pulse.  It  is  present  in  fevers, 
goiter,  hemorrhage  or  tumor  at  the  base  of  the  brain,  various 
forms  of  heart  disease  and  it  may  be  produced  by  drugs  which 
either  stimulate  the  sympathetic  or  inhibit  the  vagus.  Tachy- 
cardia being  a  symptom  rather  than  a  disease,  the  pathology 
depends  upon  the  underlying  causative  condition.  A  perma- 
nent tachycardia  may  be  physiological,  an  intermittent  one  is 
always  pathological. 

Symptoms. — Tachycardia  is  itself  a  single  symptom,  rapid 
heart  action.  When  it  becomes  noticeable  to  the  patient  it  is 
called  palpitation.  There  are  usually  incidental  symptoms 
belonging  to  the  underlying  cause.  There  is  sometimes  a 
precordial  distress  and  in  those  cases  in  which  it  is  natural 
to  the  individual,  slight  exertion,  or  emotion  will  produce 
palpitation. 

Treatment. — The  treatment  depends  upon  the  cause.  If 
no  cause  can  be  found  in  permanent  tachycardia  and  the  indi- 
vidual is  in  good  health  nothing  should  be  done.  If  inter- 
mittent and  no  cause  can  be  found,  the  patient  should  lie  down 
with  an  ice  bag  placed  over  the  heart.     If  the  organ  is  strong 


170  PATHOLOGICAL   OLD    AGE 

and  the  sounds  are  clear,  5 -minim  doses  of  tincture  of  aconite 
should  be  given.  If  the  heart  sounds  are  weak,  2 -minim  doses 
of  aconite  combined  with  1/50  grain  of  strychnine  should  be 
used.  Tincture  of  digitalis  is  useless  as  its  action  is  too  slow. 
Gelsemium  or  veratrum  viride  may  be  substituted  for  aconite  in 
the  same  dose.  The  treatment  of  palpitation  also  applies  to 
tachycardia. 

Adams-Stokes  Disease 

This  is  a  form  of  transmittory  arrhythmia  in  which  epileptoid 
attacks  occur  at  irregular  intervals. 

Etiology. — It  occurs  most  frequently  in  cases  of  arteriosclero- 
sis, occasionally  in  cases  having  a  history  of  syphilis  or  rheuma- 
tism. Neither  the  cause  of  the  disease  nor  that  of  the  attacks 
is  known;  the  attacks  have  occured  when  the  patient  had 
been  at  complete  rest  or  even  in  bed  for  several  days  and  also 
after  slight  or  intense  excitement. 

Pathology. — In  most  cases  a  lesion  in  the  bundle  of  His  has 
been  found,  but  pathologists  have  reported  autopsies  of  cases 
that  had  shown  the  symptoms  of  the  disease,  without  finding  a 
lesion  which  could  stand  in  a  causal  relation  to  it.  On  the 
other  hand  McElroy  reported  a  case  that  on  autopsy  showed 
almost  complete  destruction  of  the  bundle  of  His  by  a  gumma, 
yet  there  was  no  symptom  or  evidence  of  the  disease  during 
life. 

Symptoms. — Before  the  first  attack  and  between  attacks  a 
bradycardia  may  be  the  only  symptom  pointing  to  the  disease 
and  the  patient  himself  may  be  unconscious  of  it.  There  is 
usually  a  jugular  pulsation  or  wave  much  more  frequent  than 
the  heart  beat,  the  usual  relation  of  the  two  being  three  to  one. 
The  attack  comes  on  suddenly  with  tinnitus,  vertigo  and 
syncope,  the  pulse  being  extremely  slow  and  weak,  lasts  a  few 
minutes  and  the  patient  recovers  feeling  weak  and  as  though 
he  had  just  escaped  death.  It  is  probable  that  many  cases  of 
sudden  death  in  the  aged  are  due  to  an  attack  of  this  disease. 

Treatment. — The  treatment  is  entirely  symptomatic. 
Where  a  cause  can  be  found,  that  cause  should  receive  atten- 
tion. The  usual  hygienic  measures  applicable  to  arteriosclero- 
sis should  be  employed.     During   the    attack    a    hypodermic 


ARRHYTHMIA  171 

injection  of  atropia  1/120  grain  and  spartein  1/4  grain  should 
be  given.  Digitalis  is  contraindicated  but  strychnine  in 
1/30-grain  dose  can  be  given. 


Arrhythmia 

Irregularity  in  rhythm  is  frequently  found  in  the  aged, 
generally  in  connection  with  organic  heart  disease.  The 
irregularity  may  be  in  rate  or  force  or  both,  temporary,  pro- 
longed or  permanent.  As  the  disturbance  in  cardiac  action  is 
transmitted  to  the  radial  artery,  thereby  affecting  the  character 
of  the  pulse,  the  various  forms  of  arrhythmia  have  been  desig- 
nated by  the  type  of  pulse,  paradoxical,  bigeminal,  trigem- 
inal, respiratory,  extrasystolic,  alternating,  etc.  As  the  radial 
pulse  in  the  aged  is,  however,  affected  by  many  factors  besides 
the  action  of  the  heart  and  is  therefore  unreliable  for  diagnos- 
tic purposes,  the  terms  usually  applied  should  not  be  used  to 
designate  the  character  of  the  arrhythmia. 

Complete  Arrhythmia. — In  complete  arrhythmia  there  is  a 
disturbance  in  the  force  and  rate  of  cardiac  action,  without 
periodicity  or  regularity  of  sequence.  In  the  sphymographic 
tracings  no  two  successive  beats  are  alike.  This  condition  is 
found  in  auricular  fibrillation,  complete  loss  of  compensation, 
advanced  exophthalmic  goiter  and  may  be  produced  by  digitalis 
or  thyroid  extract.  The  irregularity  may  be  extreme  producing 
delirium  cordis  or  it  may  be  so  mild  as  to  be  unnoticed  and  un- 
known until  an  examination  of  the  heart  is  made. 

Partial  Arrhythmia. — In  incomplete  or  partial  arrhythmia 
there  is  a  periodicity  or  regularity  of  sequence  in  the  irregularity 
of  rate,  or  force  or  both.  It  may  be  physiological  or  patho- 
logical. 

In  physiological  or  respiratory  arrhythmia,  the  beats  are 
accelerated  and  stronger  during  inspiration  and  slowed  with 
expiration.     Normally  the  difference  is  very  slight. 

Exaggerated  respiratory  arrhythmia,  the  sinus  arrhythmia 
of  Mackensie,  in  which  the  difference  becomes  marked,  occurs 
in  neurasthenia,  convalescence  and  in  cerebral  diseases.  The 
force  may  be  lessened  when  the  rate  is  increased  during  inspira- 
tion, as  in  pericarditis  and  weak  heart.  The  pulse  is  then 
called  paradoxical  pulse.     Exaggerated  respiratory  arrhythmia 


172  PATHOLOGICAL   OLD   AGE 

is  supposed  to  be  due  to  a  change  in  the  irritability  of  the  vagus 
center  in  the  medulla  and  can  be  controlled  by  atropia.  The 
arrhythmia  is  increased  by  forced  breathing  and  diminished  by 
holding  the  breath. 

Extrasystolic  Arrhythmia. — In  this  form  there  is  a  second 
systolic  beat  rapidly  following  the  first  or  normal  systole  with 
a  consequent  prolonged  diastole.  Meltzer  devised  the  formula 
that  the  diastolic  pause  between  the  normal  and  extrasystole 
plus  the  diastolic  pause  following  the  extrasystole  equals  two 
systoles.  The  extrasystole  is  not  a  supernumerary  but  an 
accelerated  beat  since  the  following  contraction  occurs  in  its 
normal  time.  There  may  be  a  second  or  even  a  third  acceler- 
ated systole  but  true  to  Meltzer's  formula  the  succeeding 
diastole  will  be  lengthened  so  that  the  sum  of  the  diastoles  will 
equal  the  sum  of  the  normal  diastoles.  This  form  of  arrhythmia 
gives  rise  to  the  bigeminal,  trigeminal,  etc.,  forms  of  pulse. 

The  studies  of  Traube,  Gaskell,  Mackensie,  Wenckebach, 
Meltzer  and  others  have  cleared  up  many  questions  as  to  the 
origin  of  the  extrasystole  but  the  nature  of  the  stimulus  which 
produces  it  in  man  is  still  unknown.  It  occurs  most  frequently 
in  hysterical  and  neurasthenic  individuals,  occasionally  in 
arteriosclerosis.  The  diagnosis  of  this  form  of  arrhythmia  is 
not  difficult,  there  being  two,  rarely  three  or  more,  beats  follow- 
ing each  other  rapidly  and  then  a  correspondingly  long  pause. 
The  patient  may  feel  a  hard  thump  or  heart  beat  corresponding 
to  the  extrasystole  (which  is  usually  louder  than  the  normal 
first  sound),  others  may  feel  a  momentary  faintness  as  though 
the  heart  stopped,  corresponding  to  the  prolonged  diastole. 
The  diagnosis  can  be  confirmed  by  the  sphymograph  and 
cardiograph. 

Transmittory  Arrhythmia. — This  form  of  arrhythmia  to 
which  the  name  heart  block  has  been  given  is  caused  by  a  dis- 
crepancy between  the  auricular  and  ventricular  contractions 
due  to  impaired  conductivity  of  the  impulses  through  the  bundle 
of  His.  In  moderate  disturbance,  there  may  be  only  a  retarda- 
tion of  impulses  causing  an  occasional  loss  of  a  ventricular  beat. 
If  the  impairment  is  greater,  frequent  beats  are  lost  either 
irregularly  or  at  regular  intervals  so  that  every  second  or  third 
beat  is  dropped.  Still  further  disturbance  may  cause  only  one 
out  of  every  two  or  three  impulses  of  the  auricle  to  reach  the 


Jugular 


Brachial 

?5  Second 

i — i — i — i — i '    '    ' '    '    ' i i i i '■■■'' 

Extrasystole.     (Tasker  Howard,  M.  D.,  New  York  Medical  Journal,  May 

3,  1913-) 


JIGHAR 


BKAfHIAl 


^Second 
i_i 1 I 1 1 '    ■    ' 1 1 i_J 1 1 1 1 1    1    1    f    1 

Auricular  Fibrillation.     (Tasker  Howard,  M.   D.,   New    York 
Medical  Journal,  May  3,  1913.) 


Jugular 


Inspiration 


v 

Expiration 


Brachial 


1     i u 


^Second, 

I      1       1       I       I       1       1       1 L_J 1 I I 1 1 1 1 


Sinus  Arrhythmia.     (Tasker  Howard,  M.  D.,  New  York  Medical  Journal, 

May  3,  1913-) 


ARRHYTHMIA  I 73 

ventricle  or  there  may  be  complete  dissociation  between  auricle 
and  ventricle,  the  latter  following  a  rhythm  of  its  own.  This 
is  termed  complete  heart  block. 

The  impairment  of  the  bundle  of  His  may  be  due  to  senile 
degeneration,  syphilis,  toxemias,  or  it  may  be  of  neurotic 
origin.  The  independent  rate  of  contraction  of  the  ventricles 
is  from  twenty-three  to  twenty-eight  per  minute ;  if  the  heart  beat 
does  not  exceed  this  number  there  is  a  complete  block.  In 
Bishop's  case  in  which  there  was  a  calcareous  nodule  in  the 
region  of  the  bundle  of  His  the  heart  rate  ranged  from  thirty- 
eight  and  forty  on  the  first  day  to  twenty  on  the  last  day. 
When  transmittory  arrhythmia  is  associated  with  epileptiform 
attacks  it  forms  Adams-Stokes  disease. 

Alternating  Arrhythmia. — This  is  the  pulsus  alternans  first 
described  by  Traube,  in  which  the  rate  is  regular  but  the  force 
is  irregular.  There  may  be  several  strong  beats  followed  by  a 
weak  beat,  or  strong  and  weak  beats  alternating  or  several 
weak  beats  with  an  occasional  strong  beat.  The  contractility 
of  the  muscle  is  impaired  either  permanently  through  degenera- 
tion of  the  myocardium  or  dilatation,  or  temporarily  through 
acute  disease  or  drugs. 

Galloping  arrhythmia  is  a  form  of  arrhythmia  in  which  a 
third  sound  is  heard  with  each  beat  of  the  heart.  It  is  a  redu- 
plication of  one  of  the  normal  sounds  usually  the  second  and 
occurs  immediately  after  the  second  sound  or  just  before  the 
first  one,  shortening  the  diastole.  The  sounds  are  suggestive 
of  the  hoof  beats  of  a  galloping  horse.  It  may  occur  tempo- 
rarily when  the  heart  is  overworked;  if  permanent  it  is  gener- 
ally due  to  the  exaggerated  rebound  of  hypertrophy  with  aortic 
arteriosclerosis. 

Embryocardia  is  a  form  of  arrhythmia  in  which  the  first 
sound  and  the  diastole  are  shortened,  the  rhythm  being  like 
the  ticking  of  a  clock.  It  is  called  the  tick-tack  heart  and  is 
heard  when  compensation  is  lost  and  in  any  condition  leading  to 
collapse. 

Treatment. — The  treatment  of  the  arrhythmias  depends 
upon  the  cause.  Only  two  types,  delirium  cordis  and  Adams- 
Stokes  disease  require  emergency  treatment  during  an  attack, 
since  they  produce  distress  apart  from  the  causative  condition. 
In  delirium  cordis  relief  can  usually  be  obtained  from  a  hypo- 


174  PATHOLOGICAL   OLD    AGE 

dermic  injection  of  atropia  i/ioo  grain  and  strychnia  i/ioo 
grain  combined  with  either  1/200  grain  aconitine  1/100  grain 
strophanthin  or  digitaline  or  1/100  grain  nitroglycerin,  the 
selection  depending  upon  their  indications,  high  blood  pressure 
and  full  rapid  pulse  demanding  aconite,  low  pressure  and 
weak  rapid  pulse  requiring  strophanthus  or  digitalis ;  high  pres- 
sure and  slow  weak  or  irregular  pulse  requires  the  nitrites. 
The  nitrites  should  not  be  used  if  the  face  is  flushed,  digitalis 
should  not  be  given  if  it  has  been  used  for  a  long  time,  and 
aconite  should  not  be  used  if  the  pulse  and  heart  beats  are 
weak.  In  some  cases  the  heart  instead  of  pitching  about  with 
varying  force  and  frequency  will  give  an  occasional  jump  like 
the  expiring  efforts  of  a  fish  out  of  water.  This  portends  a 
speedy  dissolution.  Spartein  in  gr.  1/2  to  gr.  ii  doses  may 
momentarily  strengthen  the  heart  increasing  the  force  and 
frequency  of  its  contractions. 

(The  treatment  of  Adams-Stokes  disease  is  given  under  that 
head.) 

Extrasystole  is  sometimes  due  to  an  overloaded  stomach 
pressing  upward  upon  the  diaphragm,  thereby  disturbing 
the  heart.  To  empty  the  stomach  by  an  emetic  or  the  bowels 
by  a  rapidly  acting  cathartic  is  the  first  indication  in  these 
cases. 

If  no  cause  for  the  arrhythmia  can  be  discovered  the  treat- 
ment must  be  symptomatic.  Rest  and  the  avoidance  of 
coffee,  tea  and  tobacco  are  imperative.  The  greatest  care  must 
be  taken  in  the  selection  of  drugs. 

If  there  is  considerable  mental  agitation  5-10  grains  of 
veronal  combined  with  3  grains  of  camphor  monobromate 
will  relieve  this  condition. 

The  ordinary  hygienic  measures  rest,  diet,  hydrotherapy, 
massage,  freedom  from  excitement,  care  of  the  bowels,  etc., 
are  necessary  adjuncts. 

ANGINA  PECTORIS 

Angina  pectoris  is  a  paroxysmal  neurosis  occurring  most 
frequently  in  connection  with  coronary  or  aortic  arteriosclerosis 
or  aneurysm.  It  also  occurs  in  myocardial  degeneration,  endo- 
carditis and  other  cardiac  diseases.     In  some  cases  no  patho- 


ANGINA   PECTORIS  1 75 

logical  causative  factor  can  be  found.  Sometimes  there  is  a 
history  of  gout,  diabetes,  syphilis,  renal  or  hepatic  disease,  but  no 
causal  relations  between  them  has  been  discovered.  Occasion- 
ally the  symptom  complex  occurs  without  the  cardinal  symp- 
tom of  paroxysmal,  precordial  pain;  this  "angina  sine  dolore" 
is  supposed  to  be  of  neurotic  origin  although  any  one  of  the 
above-mentioned  causal  conditions  may  be  present.  In  func- 
tional angina  pectoris,  misnamed  pseudo-angina,  the  under- 
lying cause  seems  to  be  a  toxin  or  a  neurotic  condition,  usually 
hysteria. 

Etiology. — Many  theories  have  been  advanced  to  explain 
the  pathogenesis  of  angina  pectoris  yet  none  will  apply  to  all 
cases.  It  is  evident  that  there  is  more  than  one  underlying  fac- 
tor or  else  there  are  several  conditions  giving  the  same  clinical 
manifestations.  One  theory  is  that  it  is  due  to  sudden  increase 
in  tension  in  the  ventricles.  Vaso-dilators  diminish  cardiac 
tension  and  they  generally  give  relief,  but  in  some  cases  they 
aggravate  the  attack.  ,  The  theory  that  it  is  due  to  myocardial 
ischemia  caused  by  sclerosis  or  spasm  of  the  coronary  artery 
may  apply  to  some  cases,  but  patients  have  died  during  an 
anginal  attack,  yet  upon  autopsy  no  coronary  disease  was  found. 
The  toxin  theory  that  the  disease  is  due  to  toxemia  holds  good 
in  but  few  cases.  Heberden's  theory  that  it  is  a  cramp  or  spasm 
of  the  heart,  brought  on  by  an  irritation  of  the  heart  muscle, 
does  not  hold  good  in  these  cases  in  which  there  is  no  change  in 
the  force  or  rhythm  of  the  heart.  McKenzie's  theory  that  it 
is  due  to  an  impairment  in  the  contractility  of  the  heart  is 
objected  to  for  the  same  reason. 

One  pathological  condition  is  almost  invariably  present  in 
angina  pectoris — the  stomach  is  dilated  with  flatus  which  is 
expelled  at  the  moment  that  the  attack  ceases.  The  intimate 
relation  between  the  stomach  and  the  heart  through  the  pneu- 
mogastric  nerve  will  explain  why  gastric  disorders  are  frequently 
reflected  in  cardiac  irritation.  An  overdistended  stomach 
pressing  upward  upon  the  diaphragm  causes  direct  irritation 
of  the  heart.  In  the  normal,  healthy  heart  this  irritation  causes 
arrhythmia,  palpitation  and  precordial  pain  and  often  gastric 
asthma.  If  the  heart  is  degenerated,  this  irritation  causes  either 
a  spasm  of  the  heart  or  the  terminals  of  the  vagus  are  irritated 
and  they  produce  the  characteristic  agonizing  pain  by  contract- 


176  PATHOLOGICAL    OLD   AGE 

ing  the  entire  organ,  or  a  limited  area  of  the  organ,  at  the 
same  time  compressing  the  sensory  nerve  endings.  This  would 
explain  the  most  frequent  cause  of  angina  pectoris.  Fear, 
shock,  anger,  etc.,  may  act  through  reflex  action  upon  the 
vagus,  while  tobacco  and  other  toxins  are  direct  irritants  of  the 
nerve.  In  all  these  cases  irritation  of  the  vagus  is  the  under- 
lying or  basic  etiological  factor.  The  true  angina  pectoris 
occurs  most  frequently  in  those  past  middle  life  and  these 
generally  have  aortic  or  coronary  arteriosclerosis  and  perhaps 
myocardial  degeneration,  and  in  addition  there  are  probably 
changes  in  the  intrinsic  ganglia  of  the  heart  and  in  the  pneumo- 
gastric  and  phrenic  nerves  due  to  impaired  nutrition.  This 
would  account  for  the  greater  frequency,  severity  and  danger 
of  angina  pectoris  in  the  aged.  In  younger  persons  the  func- 
tional angina  due  to  neurotic  or  to  toxic  causes  is  the  more 
frequent  one. 

Symptoms. — The  cardinal  symptoms  are  an  intense  par- 
oxysmal pain  over  the  heart,  a  sense  of  faintness  and  an  agoniz- 
ing fear  of  death.  The  heart  feels  as  if  it  were  suddenly  cramped 
or  crushed  and  the  patient  will  either  be  afraid  to  move  or  he 
will  clutch  at  his  chest  as  though  he  would  grasp  the  heart. 
The  pain  is  sometimes  localized,  more  often  it  extends  to  the 
neck  and  goes  down  the  left  arm.  In  some  cases  the  pain 
seems  to  involve  the  whole  chest,  back,  neck  and  arms.  The 
face  becomes  pale  and  ashy  colored,  there  is  a  cold  sweat  and 
in  some  cases  there  is  the  "facies  Hippocrates"  which  is  seen 
just  before  dissolution.  Death  sometimes  occurs  during  the 
attack  or  in  the  syncope  following  the  attack.  In  some  cases 
there  is  arrhythmia  or  a  feeble  fluttering  heart,  in  some  there 
appears  to  be  no  change  in  the  force  or  rhythm  while  in  others 
there  may  be  palpitation  with  increased  force  in  the  pulse. 

In  some  cases  there  is  a  wheezing  respiration  and  dyspnea, 
a  further  evidence  that  the  vagus  is  disturbed.  The  attack 
ends  with  the  expulsion  of  gas  from  the  stomach.  The  whole 
cycle  lasts  a  few  seconds,  rarely  minutes.  In  the  functional 
angina  pectoris  the  attack  is  not  so  severe  and  it  is  usually  pro- 
longed, lasting  several  minutes.  The  pain  does  not  radiate  to 
the  neck,  there  is  generally  arrhythmia,  syncope  is  frequent, 
but  death  during  an  attack  is  rare.  These  attacks  usually  end 
with  the  excretion  of  a  large  quantity  of  urine.     Hysteria  is  a 


ANGINA   PECTORIS  1 77 

prominent  factor  in  many  of  these  cases.  A  toxic  form  of  angina 
pectoris  is  brought  on  by  excessive  smoking  or  tea  or  coffee 
drinking.  In  this  form  the  pains  are  spasmodic,  lancinating 
and  may  come  on  intermittently  for  hours.  Palpitation, 
dyspnea,  nausea,  syncope,  occasionally  trembling  and  profuse 
sweating  are  the  symptoms  encountered  in  this  form  of  the 
disease. 

In  the  "angina  sine  dolore"  there  are  the  sudden  sense  of 
faintness  and  fear  of  death,  with  a  precordial  ache  or  distress 
but  without  the  agonizing  pain  of  true  angina  pectoris.  Like 
the  latter  it  lasts  but  a  few  seconds  and  is  usually  followed  by 
eructations  of  gas.     There  is  usually  arrhythmia  and  dyspnea. 

Diagnosis. — True  angina  pectoris  cannot  be  mistaken.  The 
functional  angina  gives  a  causal  history,  the  attacks  are  milder, 
longer  and  more  frequent.  A  mistake  may  be  made  if  the 
patient  is  seen  for  the  first  time  during  a  severe  attack  of  func- 
tional angina  pectoris.  If  no  causal  history  or  history  of  pre- 
vious attacks  is  obtainable  it  may  be  necessary  to  wait  until  the 
attack  is  over  before  a  definite  diagnosis  can  be  made. 

Treatment. — In  the  treatment  of  angina  pectoris  the  most 
important  indication  is  the  immediate  relief  of  the  attack. 
In  some  cases  the  inhalation  of  5  minims  of  nitrite  of  amyl 
will  cause  immediate  subsidence  of  the  pain.  It  is  probable 
that  in  these  cases  there  is  a  spasm  of  the  coronaries  producing 
myocardial  ischemia  and  consequent  weakness  of  the  cardiac 
walls.  This  allows  an  increased  influx  of  blood  without  a 
corresponding  expulsion  and  increased  tension  in  the  cavities. 
This  would  substantiate  two  of  the  theories  advanced  to  ex- 
plain the  pathogenesis  of  the  disease.  In  some  cases  vaso-dila- 
tors  increase  the  severity  of  the  attack  and  we  must  resort  to 
chloroform  inhalations,  giving  few  drops  at  a  time.  As  quick 
action  is  necessary  during  the  attack,  if  amyl  nitrite  is  not  at 
hand,  a  hypodermic  injection  of  1  minim  of  a  1  per  cent, 
solution  of  nitroglycerin  should  be  given.  If  the  patient  has 
once  had  an  attack  he  should  be  instructed  to  carry  nitrite 
of  amyl  pearls  with  him  and  as  there  is  usually  a  prodromal 
sense  of  uneasiness  in  the  cardiac  region  before  the  attack, 
he  should  crush  a  pearl  in  a  handkerchief  and  inhale  it.  The 
pearls  can  be  obtained  in  silk  bags  which  can  be  crushed  between 
the  fingers.  At  such  times  every  second  is  precious.  If 
12 


178  PATHOLOGICAL   OLD    AGE 

neither  amyl  nitrite  nor  chloroform  gives  relief,  we  must  give  a 
hypodermic  injection  of  1/4  grain  of  morphine  combined 
with  1/100  grain  of  atropia.  If  there  is  palpitation  an  ice  bag 
over  the  heart  is  generally  of  service. 

As  the  attacks  occurring  in  the  aged  are  almost  always  asso- 
ciated with  coronary  or  aortic  sclerosis  and  cardiac  degenera- 
tion, the  treatment  between  attacks  should  be  directed  to  these 
conditions.  In  the  functional  anginas  whether  neurotic  or 
toxic,  the  underlying  cause  must  receive  attention.  Smoking, 
tea  and  coffee  are  injurious  in  all  cases.  Excitement  and 
laborious  tasks,  especially  such  as  require  a  sudden  exertion, 
must  be  avoided.  Sudden  ane  powerful  emotions  have  been 
known  to  bring  on  attacks  or  aggravate  the  disease  by  increas- 
ing their  frequency  and  severity.  In  some  cases  of  functional 
angina  we  can  find  no  causative  factor  and  we  must  eliminate 
everything  that  might  be  considered  injurious,  even  tea  and 
coffee  though  these  had  been  used  sparingly;  we  must  avoid 
all  physical  strains,  including  straining  at  stool,  and  all  sources 
of  excitement. 

(For  the  treatment  of  coronary  sclerosis,  see  Arterioscle- 
rosis, and  for  cardiac  degeneration  see  chapter  on  Cardiac 
Degenerations.) 

SENILE  BRONCHITIS 

This  form  of  bronchitis  is  an  atrophic  catarrh  of  the  degen- 
erated mucous  membrane  of  the  air  passages.  It  is  a  purely 
senile  condition. 

Etiology. — It  occurs  most  frequently  in  those  who  live  in 
houses  heated  by  hot  air  or  where  no  provision  is  made  to 
keep  the  air  humid.  They  rapidly  develop  an  atrophic  state  of 
the  mucous  membranes  with  diminished  sensibility  and  less- 

0 

ened  secretion.  Dust  collects  upon  this  mucous  membrane 
and  owing  to  the  diminished  sensitiveness,  the  dust  does  not 
create  the  sensory  irritation  necessary  to  produce  cough  which 
would  dislodge  it.  The  expired  air  is  not  expelled  with  suf- 
ficient force  to  carry  off  the  deleterious  substances  with  which 
the  lining  membrane  of  the  bronchi  is  coated  and  they  produce 
a  constant  irritation  of  the  membrane  with  increase  in  the  flow 
of  mucus. 


CL    CL 


Jugular 


Aa/WVaAa^ 


Brachial 


y$  Second 
»    »    t  .  i    »    iii    i    i    \    \    \    i — i — i 

Alternating  "Arrhythmia.     (Tasker  Howard,  M.  D.,  New   York  Medical 

Journal,  May  3,  1913.) 


Transmitting     Arrhythmia.        Partial     Heart     block.       (Tasker 
Howard,  M.  D.,  New  York  Medical  Journal,  May  3,  1913.) 


SENILE   BRONCHITIS  1 79 

Pathology. — There  are  the  usual  senile  changes  in  the  bron- 
chial tubes,  atony  and  waste  of  the  muscular  fibers,  atrophy 
of  the  mucous  membrane  which  becomes  loose  and  flabby 
with  diminished  sensitiveness  and  waste  of  the  ciliated  epi- 
thelium. The  glands  are  atrophied  but  there  is  a  slight  flow  of 
thin  mucus  mixed  with  epithelium,  leucocytes  and  dust.  The 
mucus  in  the  finer  bronchioles  may  be  thick  and  tenaceous. 
The  tubes  are  coated  with  dust  imbedded  in  mucus. 

Symptoms. — The  principal  symptom  is  a  morning  cough  by 
which  a  small  amount  of  mucus  is  brought  up,  usually  after 
considerable  effort.  The  mucus  is  thick,  dark,  tenaceous  and 
free  from  pus.  It  contains  epithelium,  leucocytes,  pigment 
granules,  dust,  etc.  The  patient  does  not  cough  during  the 
day  unless  he  has  made  some  great  effort  in  which  the  lungs 
were  used  excessively,  as  in  shouting  or  much  talking,  or 
if  there  has  been  excessive  irritation  as  by  inhaling  irritating 
vapors,  or  entering  a  very  dusty  apartment.  Certain  forms  of 
dust  or  vapor  may  be  more  irritating  than  others,  as  tobacco 
smoke,  the  vapor  of  roasting  coffee,  pollen,  etc.  In  such  case 
the  cough  may  be  paroxysmal,  very  severe  and  exhausting 
yet  yielding  nothing  more  than  a  drop  of  inspissated  mucus. 

The  physical  signs  of  senile  bronchitis  are  in  evidence 
before  the  morning  cough  but  not  afterward.  The  first  few 
respirations — after  the  patient  has  arisen  and  the  level  of  the 
mucus  has  been  changed — will  bring  out  moist  rales,  heard  best 
in  the  lower  part  of  the  chest  near  the  spinal  column  where 
the  mucus  had  collected  by  gravitation.  After  the  mucus  had 
been  coughed  up  the  chest  is  free  from  rales.  Percussion  may 
reveal  a  duller  note  where  the  mucus  had  accumulated. 

This  form  of  bronchitis  is  differentiated  from  other  forms 
by  the  scanty  secretion,  absence  of  signs  after  the  morning 
cough,  absence  of  temperature,  absence  of  pain  except  when  a 
paroxysmal  cough  is  induced  during  the  day,  its  persistence  and 
its  occurrence  at  any  time  of  the  year.  In  senile  emphysema 
rales  are  heard  in  the  back  immediately  upon  arising  but  they 
are  sibilant  or  snappy  caused  by  the  opening  of  the  air  vesicles 
which  had  been  compressed  while  the  patient  was  in  the 
recumbent  position.     There  is  no  cough  in  this  condition. 

Treatment. — Senile  bronchitis  may  be  relieved  by  medicinal 
measures  but  a  cure  can  be  effected  only  if  the  cause  is  removed. 


l8o  PATHOLOGICAL   OLD    AGE 

A  dense  humid  atmosphere  free  from  dust  and  vapors,  and  an 
equable  climate  are  imperative.  This  can  best  be  obtained  near 
the  seashore  either  in  Florida  or  southern  California.  High 
elevations  should  be  avoided.  The  activity  of  the  mucous 
glands  should  be  stimulated  and  for  this  purpose  nothing 
equals  the  syrup  of  the  hypophosphite  of  ammonium,  given  in 
dram  doses  every  four  hours. 

Menthol  and  eucalyptol  inhalations  are  stimulating  and 
may  be  used  for  the  upper  air  passages.  If  the  secretion  is 
thick  and  tenaceous  the  muriate  of  ammonia  should  be  given 
in  5 -grain  doses  three  or  four  times  a  day  and  if  there  is  any 
difficulty  in  expectoration,  senega,  ipecac,  squills  or  similar 
expectorants  may  be  tried. 

Morphine,  codeine,  atropine  and  other  drugs  which  di- 
minish the  secretions  are  contraindicated.  Spasmodic  attacks  of 
coughing  can  generally  be  relieved  by  the  bromides,  preferably 
the  bromide  of  ammonium. 

SENILE  GASTRIC  CATARRH 

The  terms  senile  gastric  catarrh,  chronic  gastric  catarrh 
and  chronic  gastritis,  when  applied  to  the  senile  degeneration 
of  the  stomach,  are  misnomers  as  there  is  neither  a  catarrhal 
nor  an  inflammatory  process.  Ewald  declares  that  there  are 
no  exclusively  senile  gastric  or  intestinal  diseases.  This  is 
true  to  the  extent  that  the  symptoms  of  senile  catarrh  may 
appear  in  earlier  life  and  that  similar  anatomical  and  physio- 
logical changes  as  occur  in  senility  may  occur  as  pathological 
conditions  earlier.  When  we  consider,  however,  that  these 
pathological  conditions  of  maturity  are  physiological  condi- 
tions in  old  age  and  that  the  altered  functions  in  old  age  are  the 
normal  functions  at  that  period  of  life  we  must  consider  the 
hyperactivity,  hypoactivity  or  perversion  of  these  functions  as 
true  senile  disorders.  As  long  as  the  manifestations  of  senility 
are  looked  upon  as  symptoms  of  a  pathological  condition  of 
maturity,  so  long  will  there  be  opposing  views  as  to  the  nature, 
character  and  treatment  of  diseases  that  appear  as  changes 
from  the  normal  senile  state.  The  condition  here  described  as 
senile  gastric  catarrh  is  one  of  these  diseases.  (The  chronic 
gastritis  which  follows  the  acute  inflammation  of  the  stomach 
will  be  described  with  acute  gastritis.) 


SENILE  GASTRIC  CATARRH  l8l 

Etiology. — Perversion  of  the  normal  function  of  the  senile 
stomach  may  occur  without  any  apparent  cause.  In  most  cases 
it  is  due  to  overfeeding  or  to  too  frequent  feeding  through 
failure  to  recognize  the  diminished  need  of  the  organism  for 
food  and  the  slower  gastric  digestion.  In  some  cases  there 
occurs  fermentation  or  decomposition  in  the  stomach,  especially 
if  meats  or  eggs  are  taken  that  had  been  long  in  cold  storage, 
or  if  beer  is  taken  with  the  meals.  Gastric  fermentation  is  less 
injurious  than  gastric  decomposition  since  toxins  are  elaborated 
in  the  latter  process  and  are  absorbed.  Excessive  amounts  of 
protein  may  remain  for  many  hours  in  the  stomach  and  if  addi- 
tional food  is  introduced  before  the  residue  has  been  disposed 
of,  food  will  constantly  be  present  in  the  stomach  in  various 
stages  of  digestion,  exhausting  the  organ.  Irritating  substances 
will  produce  an  acute  catarrhal  or  inflammatory  condition,  not 
the  chronic  condition  here  described.  Improperly  masticated 
food  may  produce  either  the  acute  or  the  chronic  condition. 

Pathology. — There  are  the  ordinary  senile  changes,  atony 
and  waste  of  muscular  fibers  permitting  a  dilatation  of  the 
organ;  thinning  of  the  mucous  membrane  and  atrophy  of  the 
glands;  diminution  in  peptic  secretion  and  in  the  amount  of 
hydrochloric  acid.  The  pyloric  sphincter  is  sometimes  hyper- 
trophied;  occasionally  there  is  atony  permitting  dribbling  into 
the  duodenum  of  undigested  or  partly  digested  food  that  should 
have  been  prepared  and  converted  in  the  stomach.  After  pro- 
longed irritation  from  the  etiological  factors  mentioned,  the 
mucous  membrane  undergoes  granular  degeneration  and  may 
disappear  almost  entirely.  In  extreme  cases  of  senile  atony  the 
stomach  is  little  more  than  a  reservoir  for  food,  with  slight 
peristaltic  power  and  little  digestive  capacity.  In  the  latter 
case,  the  digestive  work  is  done  by  the  intestines  and  as  long 
as  they  are  able  to  carry  on  this  work  the  nutrition  of  the 
organism  will  continue  unimpaired.  When  the  intestines  fail 
the  grave  results  of  inanition  quickly  follow. 

Symptoms. — The  symptoms  of  senile  gastric  catarrh  are 
for  the  most  part  exaggerations  of  the  normal  senile  manifesta- 
tions and  coming  on  slowly  and  gradually  they  are  not  noticed 
by  the  individual  until  a  pathological  condition  has  been  pro- 
duced or  secondary  symptoms  appear.  The  earliest  of  the 
primary    symptoms   is    anorexia.     The    appetite   is    normally 


182  PATHOLOGICAL   OLD    AGE 

diminished  in  the  aged  and  if  the  senile  changes  are  far  advanced 
the  appetite  may  fail  altogether.  There  is  a  sense  of  fulness  in 
the  stomach  lasting  sometimes  for  hours  after  a  meal.  Flatu- 
lence and  eructation  of  gas  are  frequent  accompaniments  of  this 
condition  and  if  the  stomach  is  dilated  with  gas,  it  may  press 
upward  upon  the  diaphragm,  disturbing  the  heart  action  and 
producing  the  syndrome  called  gastric  asthma.  If  this  occurs 
there  is  palpitation  or  arrhythmia  of  the  heart,  dyspnea,  and 
if  severe  there  may  be  vertigo,  syncope  and  even  collapse. 
The  cases  of  sudden  or  rapid  death  from  acute  indigestion  are 
cases  where  the  rapid  and  excessive  formation  of  gas  in  a  dilated 
stomach  caused  sudden  disturbance  of  the  heart  action  with 
consequent  paralysis  of  the  heart  or  interference  with  the  cere- 
bral circulation.  Vomiting  is  rare  except  when  the  stomach  is 
overloaded  with  food  and  even  then  some  extraordinary  irrita- 
tion is  required  to  arouse  a  sufficiently  powerful  reflex  action 
to  cause  vomiting. 

Cabot  says  "any  type  of  dyspepsia,  any  sort  of  genuine 
gastric  trouble  occurring  in  a  person  over  forty  years,  who  has 
never  had  any  such  trouble  before,  is  strongly  suggestive  of 
cancer."  After  the  age  of  sixty  senile  gastric  catarrh  occurs 
far  more  frequently  than  malignant  disease,  and  Cabot's  state- 
ment should  apply  only  to  the  period  between  forty  and  sixty. 
It  is  sometimes  impossible  to  make  a  positive  early  diagnosis 
of  carcinoma  of  the  stomach,  as  the  earliest  symptoms  resemble 
the  early  symptoms  of  senile  gastric  catarrh,  there  being  in 
both  gastric  dilatation  and  hypoacidity.  As  vomiting  is  rare 
in  the  senile  form  of  dilatation  which  is  due  to  atony  and  it  is 
an  early  symptom  of  dilatation  due  to  obstruction  of  the  py- 
lorus, this  may  serve  to  differentiate  cancer  from  senile  catarrh. 
If  vomiting  does  occur  in  senile  catarrh  it  is  due  to  excessive  or 
improper  food  and  the  substance  brought  up  is  food  in  various 
stages  of  digestion  but  there  is  little  mucus  and  no  blood.  The 
vomited  matter  in  cancer  almost  always  contains  mucus  and 
often  blood.  The  later  symptoms  of  carcinoma  are  sufficiently 
distinctive  to  prevent  an  error  in  diagnosis.  The  absence  of 
pain  in  senile  gastric  catarrh  is  a  strong  diagnostic  point  for  the 
elimination  of  ulcer,  cancer  and  acute  and  chronic  gastritis. 
Senile  gastric  catarrh  can  be  differentiated  from  chronic  gastric 
catarrh  which  is  secondary  to  the  acute  form  by  the  absence  or 


SENILE    GASTRIC    CATARRH  1 83 

small  quantity  of  mucus  which  is  brought  up,  while  in  the 
chronic  or  secondary  form  a  large  quantity  of  mucus  is  vomited. 
There  is  also  a  history  in  the  case  of  the  secondary  form  which 
determines  the  underlying  cause. 

Treatment. — The  treatment  of  senile  gastric  catarrh  com- 
prises dietary  and  hygienic,  medical  and  mechanical  measures. 
The  first  indication  is  to  clean  out  the  stomach.  Some  authori- 
ties say  lavage  is  easily  accomplished  in  the  aged  owing  to 
lessened  sensibility  of  the  pharynx,  esophagus  and  stomach. 
On  the  other  hand  spasm  of  the  muscles  of  deglutition  and  of 
the  glottis  is  easily  induced  and  a  fatal  asphyxia  may  result. 
To  prevent  spasm  a  spray  containing  2  per  cent,  of  cocaine 
should  be  used  in  the  throat  and  a  stomach  tube  of  small  caliber 
should  be  employed.  A  3  per  cent,  solution  of  boracic  acid 
can  be  used  to  wash  out  the  stomach.  After  lavage  the 
stomach  should  be  given  a  rest  for  two  hours,  after  which 
give  1/50  grain  of  strychnine  or  5  minims  of  the  tincture  of 
nux  vomica  combined  with  a  dram  of  compound  tincture  of 
gentian  or  Colombo  and  the  same  amount  of  water.  Food 
can  be  given  ten  or  fifteen  minutes  later.  Excellent  results 
have  followed  the  foregoing  plan  of  treatment.  Lavage  can 
be  employed  every  day  for  three  or  four  days,  then  every  second 
or  third  day.  The  food  should  be  concentrated  containing 
little  meat  and  little  cellulose.  Predigested  foods  are  recom- 
mended but  most  of  the  foods  of  this  character  contain  a  large 
percentage  of  alcohol.  The  patient  may  take  meat  juice,  soft 
boiled  eggs,  cream,  malted  or  evaporated  milk,  toasted  bread, 
well-boiled  vegetables  containing  little  cellulose,  etc.  Water 
acidulated  with  hydrochloric  acid  should  be  taken  during  the 
meal.  Ewald  recommends  that  the  water  should  be  as  strongly 
acid  as  the  patient  can  swallow  without  difficulty  and  it  should 
be  taken  after  meals.  As  liquid  introduced  into  the  stomach 
filled  with  food  does  not  mix  with  the  food  but  passes  off  into 
the  duodenum,  the  advice  to  take  the  acidulated  water  after 
meals  is  irrational.  Pepsin  should  be  given  with  or  immediately 
following  the  meal.  If  there  is  much  flatulence  charcoal  in  5- 
grain  doses  should  be  added  to  the  pepsin.  Incidental  measures 
are  the  simple  bitters  like  gentian,  Colombo,  cinchona  and 
quassia  in  dram  doses  of  the  tincture  or  5  grains  of  orexine  for  the 
anorexia,  and  nux  vomica  as  a  tonic  and  a  glass  of  hot  water 


184  PATHOLOGICAL   OLD   AGE 

containing  a  teaspoonful  of  common  salt  or  phosphate  of  soda 
upon  arising.  This  washes  away  the  mucus  with  which  the 
inner  surface  of  the  stomach  becomes  coated  during  the  night, 
and  it  also  acts  as  a  mild  laxative. 

It  is  sometimes  possible  to  relieve  a  gastric  catarrh  by 
these  means  alone  if  the  stomach  is  then  given  complete  rest 
for  the  day  and  the  saline  hot  water  is  repeated  at  bedtime. 
The  diet  must  thereafter  be  selected  to  give  the  stomach  as 
little  work  as  possible  and  to  produce  as  little  gas  as  possible. 
We  must  warn  again  against  meat,  fish  and  eggs  that  have  been 
kept  long  in  cold  storage  or  have  been  preserved  with  chemicals. 
Nausea  and  vomiting  are  rare  and  if  vomiting  occurs  it  is 
nature's  method  of  getting  rid  of  offending  material.  If 
there  is  nausea  and  the  stomach  is  filled  with  food,  5  grains  of 
pepsin  should  be  given  to  aid  digestion  and  1/4 -grain  aloin  to 
stimulate  stomach  peristalsis.  If  the  nausea  occurs  when 
the  stomach  is  empty  it  may  be  due  to  an  accumulation  of  mucus 
in  the  stomach.  Occasionally  nausea  upon  arising  will  be 
caused  by  the  accumulation  of  mucus  in  the  pharynx.  In 
either  case  hot  water  containing  a  small  quantity  of  salt  should 
be  taken  to  dislodge  the  mucus.  A  persistent  nausea  when 
the  stomach  is  empty  is  rapidly  relieved  by  1/12  grain  of  cocaine 
hydrochlorate.  This  will  also  relieve  gastrodynia.  Pyrosis 
is  infrequent  in  the  aged  but  if  it  does  occur  5  grains  of  bismuth 
subnitrate  combined  with  either  1/12  grain  of  cocaine  or 
morphine  should  be  used.  If  hyperacidity  occurs  it  is  due  to 
acetic,  butyric  and  lactic  acids,  all  decomposition  products. 
Alkalies  which  cure  hyperacidity  in  maturity  are  contra- 
indicated  in  the  aged  and  we  must  resort  to  antifermentives 
like  salicylic  acid,  boracic  acid,  creosote,  charcoal,  etc.,  to  prevent 
further  fermentation  and  decomposition. 

The  most  important  hygienic  measures  are  freedom  from 
worry,  mild  exercise  and  regulation  of  the  bowels.  A  temporary 
constipation  may  undo  in  two  days,  all  the  good  obtained  by 
several  weeks'  treatment.  Salines  should  be  given  either  in 
an  occasional  large  dose  or  in  small  doses  for  several  days. 
They  should  not  be  given  in  habitual  constipation.  The 
ordinary  senile  constipation  should  be  treated  as  indicated  in 
the  chapter  on  Senile  Degeneration  of  the  Intestines. 


GASTRIC   NEUROSES  1 85 

GASTRIC  NEUROSES 

Gastric  neuroses  occur  rather  frequently  in  the  aged. 

While  some  of  these  diseases  are  rare  in  the  aged  and  others  are  apparently 
associated  with  hysteria  or  neurasthenia,  they  are  all  placed  in  the  second  group 
of  diseases  upon  the  assumption  that  most  of  the  neuroses  occurring  in  the  aged 
are  due  to  the  senile  change  in  the  nervous  system,  to  arteriosclerosis  or  change  in 
the  stomach  or  its  secretions. 

Pneumatosis  or  distention  of  the  stomach  with  gas  which 
the  stomach  cannot  dispel  owing  to  atonicity  of  the  walls  is 
of  frequent  occurrence.  It  is  one  of  the  causes  of  gastric  asthma, 
the  dilated  and  distended  stomach  pressing  upward  upon  the 
diaphragm  and  thus  upon  the  heart.  The  treatment  of  this 
condition  is  the  treatment  of  gastric  atonicity.  If  rapid 
eructation  of  gas  is  necessary  10  to  20  minims  of  oil  of  turpen- 
tine should  be  given  and  pressure  applied  over  the  stomach. 
Turpentine  stupes  over  the  abdomen  will  give  temporary  relief. 
In  some  cases  5  grains  of  willow  charcoal  and  5  grains  of  sodium 
bicarbonate  will  be  more  effectual  than  the  turpentine.  To 
prevent  excessive  fermentation  dilute  hydrochloric  acid  should 
be  given  with  every  meal.  Nervous  eructations  are  infrequent 
in  the  aged.  They  may  occur  when  food  is  taken  in  too  rapid 
intervals. 

Pyrosis  or  heartburn  is  usually  due  to  gastric  dilatation 
with  hyperacidity.  Hyperacidity  being,  however,  rare  in  the 
aged,  pyrosis  is  also  rare.  When  it  does  occur,  the  underlying 
condition  must  be  treated.  For  immediate  relief  we  can  give 
1/8  grain  of  cocaine. 

Grastrospasm  either  at  the  cardiac  or  pyloric  orifice,  is  oc- 
casionally met  with  in  old  age.  It  sometimes  follows  a  cold 
drink,  a  strong  alcoholic  beverage,  sharply  spiced  food  or  strong 
emotion.  Pyloric  spasm  may  follow  an  excessive  meal  or  food 
improperly  or  insufficiently  masticated.  In  some  cases  no 
cause  can  be  discovered.  The  treatment  depends  upon  the 
cause,  if  discoverable.  In  other  cases  abstinence  from  food 
will  frequently  give  relief.  The  bromides  are  useful  in  this 
condition. 

Relaxation  of  the  pylorus  occurs  occasionally  from  atony  of 
the  pyloric  sphincter.  (This  is  described  under  the  Senile 
Degeneration  of  the   Stomach.)     Other  causes  are   shock  or 


1 86  PATHOLOGICAL    OLD    AGE 

strong  sudden  emotion  such  as  fright ,  etc .  A  persistent  relaxation 
may  be  suspected  when  there  is  a  lientery  containing  meat  fibers. 
The  treatment  depends  upon  the  cause.  Nothing  can  be  done 
for  the  temporary  condition  due  to  shock,  fright  or  similar 
causes.     Supermotility  does  not  occur  in  the  aged. 

Secretory  neuroses  are  infrequent  in  the  aged.  Hyperchlor- 
hydria  and  gastrosuccorrhea  are  extremely  rare  and  hypochlor- 
hydria  as  part  of  an  achylia  gastrica  is  a  normal  condition  in  the 
aged,  due  to  atrophy  of  the  secreting  glands.  This  is  not  a 
neurosis  but  a  true  senile  degeneration  for  which  nothing  can 
be  done.  Where  it  exists  we  can  supply  the  deficiency 
artificially. 

Sensatory  neuroses  occur  rather  frequently,  the  most  promi- 
nent being  anorexia. 

Diminished  appetite  is  natural  in  the  aged.  Diminished 
activity  causes  less  waste  and  less  expenditure  of  energy,  and 
less  food  is  consequently  required.  Other  factors  which  tend 
to  diminish  the  appetite  in  the  aged  are  lessened  salivary  secre- 
tion, dysphagia,  and  some  change  in  the  taste  bulbs.  Nothing 
need  be  done  for  this  but  if  there  is  complete  anorexia,  the 
appetite  must  be  stimulated  by  means  of  simple  bitters.  Orex- 
ine  is  especially  useful  in  this  condition.  It  is  given  in  io-grain 
doses  about  an  hour  before  meals. 

Bulimia  does  not  occur  in  the  aged  except  as  a  symptom  of 
diabetes,  and  occasionally  during  convalescence  from  pro- 
longed illness.  It  requires  no  treatment.  The  elixir  of  the 
valerianate  of  ammonia  has  been  found  to  diminish  the  appetite 
but  it  is  rarely  necessary  to  give  it. 

Parorexia  or  perverted  appetite  occurs  occasionally  where 
the  taste  for  ordinary  foods  is  lost.  This  is  generally  due  to 
gustatory  perversion,  and  manifests  itself  in  a  malacia,  the 
patient  craving  spiced,  acid  or  acrid  foods.  The  craving  for 
indigestible  substances  such  as  occurs  in  hysteria  does  not 
occur  in  the  aged  unless  associated  with  hysteria,  dementia  or 
other  psychosis.  The  painful  gastric  neuroses  are  rare  in  the 
aged. 

Hyperesthesia  may  occur  during  neurasthenia  or  after  a 
shock,  fright  or  other  strong  emotion  but  it  does  not  last  longer 
than  a  few  hours.  Suggestion  or  autosuggestion  may,  however, 
cause  its  reappearance  and  from  this  cause  it  may  become  per- 


GASTRIC   NEUROSES  1 87 

manent.  In  this  as  in  other  painful  neuroses  psychic  measures 
will  often  avail  while  drugs  will  be  useless. 

Gastralgia  or  gastrodynia  is  another  painful  neurosis  which 
may  be  due  to  suggestion.  It  is  generally  associated  with 
neurasthenia,  the  attacks  being  most  severe  when  the  indi- 
vidual is  most  depressed.  The  pain  comes  on  independently 
of  food  and  in  some  cases  taking  food  gives  relief.  Gastralgia 
resembles  a  colic,  moderate  pressure  giving  relief  while  deep 
pressure  will  uncover  a  point  of  tenderness.  Hepatic  colic  is 
more  painful  and  the  tender  point  is  usually  to  the  right  of  the 
sternum  and  umbilicus;  intestinal  colic  is  more  diffuse  and  not 
over  the  stomach;  renal  colic  has  also  a  pathognomonic  site 
between  the  kidney  and  the  bladder.  Cancer  and  ulcer  are 
readily  differentiated  from  simple  gastralgia.  Gastric  ulcer  is 
rare  in  old  age  and  it  can  be  distinguished  by  the  presence 
of  a  hyperchlorhydria.  In  cancer  the  history,  cachexia,  vomit- 
ing, localized  pain  and  later  the  presence  of  a  growth  ought  to 
differentiate  it  from  gastrodynia.  Intercostal  neuralgia  is 
more  severe,  is  higher  up  and  more  localized. 

In  the  treatment  of  the  painful  senile  neuroses,  psychic 
measures  will  often  avail.  When  drugs  are  required  bromide 
of  sodium  or  strontium  should  be  used  and  in  an  emergency  for 
the  more  rapid  relief  of  pain  we  can  use  cocaine  or  eucain.  The 
narcotics  should  not  be  used.  Acidulated  waters  are  generally 
well  borne.  Regulation  of  the  diet  will  in  some  cases  com- 
pletely cure  a  neurosis,  and  in  some  cases  a  day's  starvation 
will  cause  the  symptoms  to  disappear. 

Esophageal  Neuroses. — Spasm  of  the  esophagus  occurs 
occasionally  in  the  aged  either  as  part  of  a  general  neurosis, 
such  as  hysteria  or  as  the  result  of  local  irritation  as  when  a 
hard  substance  is  swallowed.  In  some  cases  there  is  a  pro- 
longed contraction  of  the  esophagus,  food  failing  to  pass  a  cer- 
tain point  for  several  minutes  or  hours,  then  passing  without 
difficulty.  In  some  cases  certain  articles  of  food,  solids  or 
liquids  cause  spasm.  As  the  underlying  cause  can  seldom  be 
discovered,  the  treatment  must  be  symptomatic,  substances 
causing  spasm  must  be  avoided  and  bromides  should  be  given. 
Galvanism,  faradization,  or  fine  rapid  vibration  sometimes 
gives  relief.  Psychic  measures  are  often  effective.  The  patient 
may  have  a  spasm  through  fear  and  if  the  fear  is  allayed  the 


1 88  PATHOLOGICAL   OLD    AGE 

spasm  will  not  occur.  In  one  case  in  which  swallowing  water 
produced  a  spasm,  a  glass  of  water  slightly  flavored  and  given 
by  the  physician  as  medicine  was  swallowed  without  difficulty. 

Globus  hystericus,  anesthesia  and  hypesthesia  are  usually 
hysterical  phenomena  and  need  no  other  treatment  than  that 
for  the  underlying  condition. 

Intestinal  Neuroses. — Intestinal  neuralgia  is  extremely  rare 
and  is  supposed  to  be  due  to  arteriosclerosis  of  the  abdominal 
aorta  or  the  mesenteric  artery.  Colic  is  almost  invariably  due 
to  the  presence  of  an  irritant  or  peristaltic  stimulant.  Exces- 
sive motility  does  not  occur  except  when  due  to  a  stimulant  and 
atony  is  almost  always  due  to  the  natural  senile  degenerative 
changes  in  the  walls.     The  treatment  depends  upon  the  cause. 

CHOLELITHIASIS 

Gall-stone  formation  is  the  most  frequent  disease  of  the 
liver  and  its  adnexa  in  old  age,  and  autopsies  frequently  reveal 
gall-stones  in  the  gall-bladder,  though  often  they  gave  no 
indication  of  their  presence  during  life. 

Etiology. — The  frequent  finding  of  gall-stones  in  the  aged 
at  autopsy,  which  gave  no  symptoms  during  life,  would  tend  to 
exclude  infection  as  the  principal  etiological  factor  and  would 
point  to  a  change  in  the  character  of  the  hepatic  secretion  or 
to  diminished  expulsive  activity  of  the  gall-bladder,  probably 
both,  causing  an  increase  in  the  proportion  of  cholestein,  some- 
times a  deposit  of  calcium  salts,  and  stasis.  The  most  prolific 
causes  in  earlier  life,  infection  and  inflammation  of  the  gall- 
bladder may  prevail  in  old  age,  but  infection  is  rare,  while 
inflammation  is  more  often  resultant  than  causative.  In  Mac- 
Carty's  statistics  nearly  70  per  cent,  of  cases  of  acute  chole- 
cystitis had  gall-stones  and  93  per  cent,  of  chronic  cholecystitis 
cases  were  associated  with  gall-stones.  As  acute  gastrointes- 
tinal catarrh  is  infrequent  in  senile  cases  and  chronic  atrophic 
catarrh  has  not  the  tendency  to  extend  through  the  common 
duct  to  the  gall-bladder  this  cause  of  cholecystitis  is  rare,  and 
we  can  assume  that  if  cholecystitis  is  present  it  is  due  in  most 
cases  to  the  irritation  produced  by  the  concretions. 

Symptoms. — As  has  been  stated  above,  many  cases  give  no 
symptoms.     In  some  cases  the  only  suspicious  symptoms  are 


CHOLELITHIASIS  1 89 

those,  connected  with  deficient  bile  supply;  clayey,  foul-smelling 
stools,  perhaps  containing  fat  globules,  a  yellowish  furred  tongue, 
bad  breath  and  sallowness.  If  in  these  cases  pressure  is  made 
over  the  region  of  the  gall-bladder  and  tenderness  is  elicited  there 
is  a  mild  cholecystitis  present  probably  due  to  gall-stones.  There 
is  no  pathognomonic  symptom  of  gall-stones  except  their  pres- 
ence in  the  stools.  The  hepatic  colic  is  caused  by  the  spas- 
modic contraction  of  the  unstriped  muscle  fibers  of  the  gall- 
bladder, in  the  effort  to  expel  and  propel  the  contents,  which  may 
be  pus,  mucus  or  blood  as  well  as  bile  concretions.  In  senile 
cases,  however,  if  these  morbid  contents  are  present,  they  are  due 
in  almost  every  case,  to  infection,  occurring  especially  during 
typhoid  fever.  The  symptoms  resolve  themselves  into  the 
symptoms  of  cholecystitis,  obstruction  of  the  ducts  and  colic. 
In  mild  cholecystitis  there  is  generally  a  dull  ache,  not  severe 
enough  to  produce  actual  suffering  but  quite  pronounced  at 
times,  and  often  we  may  elicit  pain  upon  pressure  over  the 
region  of  the  gall-bladder,  and  in  the  back  about  an  inch  to  the 
right  of  the  eleventh  dorsal  vertebra.  In  pronounced  inflam- 
mation the  pain  is  severe  and  there  is  fever,  either  intermittent 
if  due  to  bacterial  infection,  or  a  steady  increased  temperature 
if  due  to  local  non-bacterial  irritation.  In  rare  cases  in  the 
aged  a  cholecystitis  exists  without  cholelithiasis  and  in  these 
cases  the  contraction  colic  is  shorter  and  milder  than  when 
gall-stones  are  present.  Jaundice  is  sometimes  observed,  and 
bile  is  occasionally  found  in  the  urine. 

When  gall-stones  lodge  in  the  common  duct  they  give  rise 
to  symptoms  of  biliary  obstruction.  (See  Biliary  Obstruction, 
page  329.)  There  is  then  deficiency  of  bile  supply  to  the  bowels, 
jaundice  and  colic.  The  jaundice  is  variable,  being  slight  in 
some  cases  and  severe  in  others,  always  deepening  after  a  colic 
paroxysm.  With  this  form  of  jaundice  we  find  bile  in  the  urine 
and  none  in  the  feces. 

The  colic  which  is  the  most  constant  and  characteristic 
attendant  of  gall-stones  occurs  in  paroxysms  which  are  fairly 
regular  when  the  duct  is  involved,  but  occurring  at  irregular 
intervals  when  the  gall-bladder  alone  is  affected.  In  senile 
cases  the  attacks  are  not  as  severe  as  in  earlier  life  nor  are  the 
chills,  sweating  and  fever  accompanying  the  pain  as  pronounced. 
The  pain  occurs  as  a  sudden  agonizing  neuralgia  in  the  right 


190  PATHOLOGICAL   OLD    AGE 

hypochondrium,  radiating  toward  the  right  shoulder.  If  the 
colic  originates  in  the  common  duct  the  pain  begins  in  the 
epigastric  region  and  radiates  backward  and  not  upward.  In 
this  case  the  remittent  jaundice  distinguishes  it  from  other 
abdominal  colics.  The  diagnosis  of  cholelithiasis  is  rather 
difficult  in  senile  cases,  owing  to  the  mildness  and  irregularity 
of  the  symptoms.  Old  cases  may  give  the  characteristic 
symptoms  of  hepatic  colic  but  usually  the  rigor,  chill  and  fever 
are  not  severe,  there  is  no  vomiting  and  but  little  sweating, 
while  jaundice  is  rare.  In  some  cases  there  are  occasional 
sharp  pangs  in  the  epigastrium  and  pain  can  be  elicited  on  pres- 
sure over  the  gall-bladder.  More  often  there  is  a  persistent 
dull  ache  in  the  epigastrium  with  the  symptoms  of  deficient 
biliary  supply  to  the  bowels.  In  these  cases  there  may  be 
paroxysms  of  pain  marking  the  passage  of  a  calculus  through 
the  duct  and  then  there  is  intense  mental  and  physical  depres- 
sion similar  to  shock.  The  diagnosis  has  often  been  confirmed 
by  radiography. 

Complications.— The  number  or  size  of  the  concretions  may 
fill  the  gall-bladder  producing  inflammation  and  ulceration. 
As  a  remote  result  rupture  of  the  organ  may  ensue,  followed  by 
rapidly  fatal  shock  or  peritonitis.  Other  complications  are 
biliary  fistula?,  intestinal  obstruction  by  gall-stones,  adhesions 
of  the  organ,  cancer. 

Treatment. — During  the  attack  relief  from  pain  is  the  only 
indication  and  for  that  purpose  there  is  nothing  that  will  take 
the  place  of  a  hypodermic  injection  of  morphine  combined  with 
atropine,  giving  1/4  grain  of  morphine  as  an  analgesic  and  1/100 
grain  of  atropine  to  counteract  the  effect  of  the  morphine  upon 
the  respiratory  centers  and  to  cause  relaxation  of  the  muscular 
fibers.  Chloroform  inhalation  will  also  give  immediate  relief 
but  is  dangerous  if  there  is  arteriosclerosis.  Olive  oil  in  from 
2-  to  6-ounce  doses  has  been  recommended  but  it  is  doubtful 
of  having  any  other  effect  except  that  of  aiding  in  the  expulsion 
of  those  calculi  that  reach  the  duodenum.  Chloral  hydrate  is 
excellent  in  younger  individuals  but  it  is  dangerous  in  the  aged. 

The  treatment  in  the  intervals  between  attacks  depends 
upon  the  severity  and  frequency,  the  amount  of  distress  and  the 
general  condition  of  the  patient  between  the  attacks.  If  the 
symptoms  are  mild  and  the  attacks  are  infrequent  operation  is 


SENILE    METRITIS  191 

unnecessary.  If  there  is  a  fatty  heart,  myocarditis  or  cardiac 
dilatation,  nothing  but  the  certainty  of  death  without  opera- 
tion will  justify  surgical  interference.  If  the  attacks  are 
frequent  and  severe  or  if  there  is  an  infective  cholecystitis, 
operation  becomes  necessary,  sometimes  even  imperative.  In 
all  other  cases,  however,  medicinal  measures  should  be  tried 
before  resorting  to  cholecystectomy  or  cholecystostomy.  There 
is  no  known  method  of  resolving  gall-stones  in  situ.  Numerous 
drugs  have  been  recommended  for  this  purpose,  those  most 
frequently  employed  being  the  sodium  choleate,  sodium  oleate, 
sodium  salicylate,  sodium  succinate  and  iron  succinate,  olive  oil 
and  oil  of  turpentine.  The  salts  have  the  property  of  stimulat- 
ing the  flow  of  bile  and  making  it  more  fluid  but  it  is  doubtful 
whether  they  have  any  effect  upon  the  concretions  already 
formed.  By  increasing  the  fluidity  of  the  secretion,  further 
formation  of  calculi  is  prevented  and  this  often  suffices  to  pre- 
vent a  recurrence  of  an  attack.  The  sodium  choleate  in  5 -grain 
doses  twice  or  three  times  a  day  has  this  effect  upon  the  bile 
and  also  supplies  the  deficiency  of  the  duodenal  secretion. 
The  sodium  succinate  acts  more  powerfully  upon  the  liver 
and  upon  the  secretion  but  has  no  effect  upon  foods  in  the 
intestinal  tract.  Drug  treatment  must  be  continued  for  months 
or  years,  as  their  effect  is  only  temporary.  If  the  attacks 
continue  during  the  drug  treatment  with  undiminished  severity 
or  reappear  after  discontinuance  of  prolonged  drug  treatment, 
operative  measures  become  necessary.  The  form  of  operation, 
whether  cholecystectomy  or  cholecystostomy,  will  depend  upon 
the  exploratory  findings  and  the  surgeon's  preference. 

SENILE  METRITIS 

Metritis  originating  after  the  menopause  and  not  associated 
with  a  growth  nor  produced  by  traumatism  is  rare. 

Etiology. — Most  of  the  reported  cases  were  due  to  the 
retention  of  mucus  through  vaginal  atresia  or  cervical  occlusion, 
with  subsequent  septic  infection.  A  hemorrhagic  form,  which 
is,  however,  extremely  rare,  is  supposed  to  be  due  to  a  cardiac 
lesion  with  consequent  venous  stasis.  Various  predisposing 
causes  have  been  suggested  but  the  cause  given  for  the  purulent 
form  is  sufficiently  potent  to  explain  every  case  of  this  form. 


192  PATHOLOGICAL    OLD   AGE 

It  occasionally  occurs  soon  after   the   menopause,    more   fre 
quently  a  few  years  later. 

Symptoms. — The  earliest  and  most  pronounced  symptom  is 
a  purulent  or  sanguinous  discharge  having  a  most  offensive 
odor.  In  some  cases  the  discharge  is  scanty,  in  others  copious; 
sometimes  intermittent,  at  other  times  continuous.  There 
is  usually  little  pain;  occasionally  a  colicky  pain  in  the  uterus 
precedes  a  sudden  gush  of  the  discharge.  In  some  cases  there 
is  a  rapidly  progressive  cachexia  with  emaciation,  sallowness, 
and  gastric  disorders.  In  making  a  digital  examination  partial 
atresia  of  the  vagina  and  a  vaginitis  are  usually  found.  The 
cervix  is  soft,  apparently  swollen  and  painful  to  the  touch. 
Examination  with  the  speculum  is  frequently  impossible  owing 
to  the  constriction  and  the  inflamed  condition  of  the  vagina. 
The  fetid  odor  and  the  cachexia  cause  this  disease  to  be  generally 
mistaken  for  uterine  cancer  and  cases  have  been  operated  upon 
which  in  their  clinical  manifestations  could  not  be  distinguished 
from  uterine  cancer.  A  curettage  scraping  should  be  examined 
in  every  case  of  doubt.  The  determination  of  the  actual 
pathological  condition  present  is  of  the  utmost  importance, 
the  life  of  the  patient  depending  upon  the  treatment,  which  is 
entirely  different  in  the  two  diseases.  If  the  curette  scraping 
does  not  clear  up  the  diagnosis  or  if  curettage  is  impracticable 
it  is  better  to  await  the  result  of  treatment  for  metritis  than  to 
conclude  that  we  are  dealing  with  a  uterine  cancer  and  proceed 
to  perform  a  hysterectomy.  The  disease  is  grave  and  while 
most  cases  recover  under  appropriate  treatment,  there  is 
always  danger  of  spreading  local  and  general  infection,  and  of 
exhaustion. 

Treatment. — The  primary  indication  is  to  clean  out  the 
uterus.  The  cervix  must  be  dilated  and  the  contents  of  the 
uterine  cavity  should  be  washed  out  with  a  mild  solution  of 
permanganate  of-  potash  or  sterile  water.  This  may  be  followed 
by  a  solution  of  peroxide  of  hydrogen.  Curettage  with  a 
sharp  curette  is  dangerous  on  account  of  the  thin  and  degen- 
erated walls,  and  with  a  blunt  instrument  it  is  useless.  Only 
the  necessity  of  arriving  at  a  correct  diagnosis  justifies  the  use 
of  the  sharp  curette  in  making  a  scraping  for  examination. 
After  the  cavity  has  been  emptied  and  cleaned  it  should  be 
packed    with    iodoform    gauze.     This    treatment    should    be 


CEREBRAL   ANEMIA  I 93 

continued  for  several  days  after  which  it  will  suffice  to  pack 
the  vagina  alone  until  the  discharge  ceases.  The  constitutional 
treatment  consists  of  absolute  rest  in  bed,  tonics  and  the  usual 
treatment  for  exhaustion.  The  same  treatment  is  indicated  in 
the  hemorrhagic  form  but  curettage  is  positively  contraindicated. 

CEREBRAL  ANEMIA 

Cerebral  anemia  is  frequently  found  in  the  aged  but  its 
advent  is  so  slow  that  the  patient  accommodates  himself  to 
the  symptoms  and  does  not  notice  them  or  ascribes  them  to  the 
result  of  ageing. 

Etiology. — It  is  generally  due  to  sclerosis  of  the  cerebral 
arteries  with  weak  heart  and  especially  with  aortic  stenosis. 

Symptoms. — When  due  to  cerebral  arteriosclerosis  there 
will  be  the  symptoms  of  this  disease,  vertigo,  dizziness,  tinnitus, 
weakened  memory  and  neuralgic  or  prolonged  headaches  with 
drowsiness  and  a  feeling  of  emptiness  in  the  head.  The  patient 
will  have  an  instinctive  desire  to  lie  down  and  the  symptoms 
will  subside  in  the  recumbent  position.  In  cerebral  arterio- 
sclerosis without  anemia  change  of  position  does  not  relieve 
these  symptoms.  Cerebral  anemia  due  to  other  causes  is  readily 
differentiated  from  this  form  which  is  peculiar  to  the  aged. 

Treatment. — The  treatment  is  the  same  as  for  cerebral 
arteriosclerosis.  The  hypodermic  use  of  sterile  solutions  of 
arsenic  and  iron  or  the  administration  of  hemoglobin  in  15- 
grain  doses  three  times  a  day  may  improve  the  character  of 
the  blood.  The  symptoms  usually  increase,  however,  and  syn- 
cope may  occur  after  any  excitement  or  even  while  but  taking 
a  hot  foot  bath.  The  nitrites  and  cardiac  stimulants  are  then 
indicated. 

ALTERNATING  CEREBRAL  ANEMIA  AND 

HYPEREMIA 

This  is  a  disturbance  of  the  cerebral  circulation  in  which 
there  is  a  progressively  increasing  anemic  condition  when  the 
patient  is  sitting  or  standing  and  a  progressively  increasing 
hyperemic  condition  when  the  patient  is  lying  down.  This 
occurs  normally  in  a  mild  degree,  prolonged  standing  causing  a 
13 


194  PATHOLOGICAL    OLD    AGE 

mild  cerebral  anemia  with  consequent  drowsiness  and  sleep. 
Some  cases  of  anemia  develop,  however,  a  pronounced  hyper- 
emia in  the  recumbent  position,  which  is  nothing  more  than  an 
exaggeration  of  what  occurs  normally.  It  is  probably  due  to 
some  defect  in  the  vasomotor  regulation  and  to  atheromatous 
but  not  calcareous  cerebral  vessels. 

Symptoms. — The  patient  awakes  with  a  dull  frontal  head- 
ache and  mental  confusion,  flushed  face,  injected  conjunctivae 
and  the  concomitants  of  cerebral  hyperemia.  These  gradu- 
ally pass  away  after  arising,  sometimes  within  a  few  minutes, 
sometimes  in  an  hour  or  two.  There  is  then  no  symptom  of 
cerebral  disturbance  for  several  hours  when  the  symptoms  of 
cerebral  anemia  appear.  The  face  becomes  pale,  lips  and  ears 
are  slightly  blanched,  the  patient  feels  tired  and  drowsy  and 
there  may  be  vertigo,  tinnitus,  headache,  and  unless  he  lies 
down,  there  will  be  syncope. 

Upon  lying  down  these  symptoms  gradually  disappear  and 
are  followed  by  the  symptoms  of  cerebral  hyperemia.  There 
is  a  gradually  increasing  frontal  headache,  a  feeling  of  heavi- 
ness, mental  dulness  and  an  instinctive  feeling  that  he  will 
be  relieved  upon  arising.  If  he  falls  asleep,  he  will  become 
restless  after  a  few  hours,  snore,  moan  and  will  awake  with  the 
symptoms  of  cerebral  hyperemia,  thus  completing  the  cycle. 

Treatment. — As  there  are  two  opposing  phases  of  this  dis- 
ease, whatever  will  benefit  the  one  will  be  detrimental  to  the 
other.  The  hyperemic  is  the  more  serious  phase  on  account  of 
the  distress  and  possible  secondary  effects.  The  anemia  can 
be  relieved  temporarily  by  the  use  of  the  nitrites,  giving 
i  minim  of  a  i  per  cent,  solution  of  nitroglycerin  when  the  symp- 
toms appear.  The  patient  will  instinctively  want  to  lie  down 
and  this  affords  speedy  relief.  For  the  hyperemia  we  need 
rapidly  acting  vasoconstrictors  like  ergot,  or  digitalin  or  stro- 
phanthin  hypodermically.  The  drug  must  be  stopped  as  soon 
as  the  effect  is  produced.  The  patient  must  lie  with  the  head 
elevated  and  upon  arising  he  should  take  a  hot  foot  bath. 
Drugs  used  for  the  relief  of  symptoms  must  be  rapidly  acting, 
the  effect  passing  away  in  a  few  hours.  There  is  no  way  of 
restoring  the  impaired  vasomotor  centers.  Strychnine  arsen- 
ate has  been  of  service  in  some  cases.  It  is  given  in  doses  of 
i/ioo  grain  three  times  a  day. 


CEREBRAL    SOFTENING  1 95 

CEREBRAL  SOFTENING 

Cerebral  softening  is  a  degeneration  of  brain  substance  due 
to  sudden  or  rapid  deprivation  of  nutrition.  It  differs  from 
the  normal  senile  degeneration  which  involves  the  whole  brain, 
proceeds  slowly  and  has  but  a  diminished  blood  supply,  while 
in  cerebral  softening  the  blood  supply  is  completely  with- 
drawn from  a  part.  It  occurs  in  two  forms — the  usual  senile 
thrombotic  form  which  comes  on  gradually  and  the  embolic 
form  which  comes  on  suddenly.  While  there  are  other  causes 
than  thrombosis  and  embolism  every  case  can  be  placed  under 
one  of  these  two  heads  of  gradual  or  sudden  form  of  cerebral 
softening. 

Etiology. — The  most  frequent  cause  of  cerebral  softening 
in  the  aged  is  a  thrombus  in  an  atheromatous  vessel  of  the 
circle  of  Willis  or  in  one  of  the  branch  vessels.  It  may  also 
occur  in  cerebral  arteriosclerosis  in  which  the  lumen  of  a  vessel 
is  obliterated.  An  embolus,  which  is  the  most  frequent  cause 
of  cerebral  softening  in  earlier  life  does  not  occur  as  frequently 
in  the  aged.  Such  accidental  causes  as  syphilis,  infectious 
diseases,  anemia,  leukemia,  etc.,  which  may  cause  endocarditis 
with  vegetations  and  consequent  embolus,  or  carbonic-acid 
poisoning,  burns,  tumors  and  other  local  conditions  which  may 
cause  thrombosis,  are  rare  in  the  aged. 

Pathology. — The  first  change  is  an  anemia  of  the  tissue  sup- 
plied by  the  vessel  which  is  blocked.  In  from  three  to  four  days 
this  tissue  begins  to  soften  into  a  creamy  or  pale  semifluid 
mass.  This  exhibits  under  the  microscope  debris  of  neuroglia, 
altered  cells  and  fibers,  a  mass  of  leucocytes  attacking  the  de- 
generated tissue  and  disposing  of  it  by  phagocytosis.  The 
destroyed  area  becomes  later  filled  with  fibrous  tissue. 

Symptoms. — The  two  forms  of  cerebral  softening  differ 
markedly  in  their  onset  but  after  the  brain  substance  has 
begun  to  degenerate  they  are  alike. 

Thrombotic  cerebral  softening  comes  on  gradually.  For 
weeks  perhaps  there  were  symptoms  of  cerebral  atheroma, 
with  headache,  vertigo,  nausea  and  occasional  confusion  of 
ideas.  As  the  nutrition  of  the  part  becomes  diminished  there 
are  symptoms  of  impaired  functions.  Numbness  in  one  hand 
and  diminishing  strength  with  gradual  loss  of  sensation  and 


196  PATHOLOGICAL   OLD    AGE 

power  set  in.  The  face  becomes  paralyzed  on  the  same  side 
and  mental  confusion  becomes  more  marked.  With  complete 
closure  of  the  vessel  the  patient  becomes  unconscious  and  the 
whole  side  is  paralyzed.  When  the  patient  recovers  from  the 
unconsciousness,  there  is  mental  confusion,  motor  paralysis 
and  in  some  cases  aphasia.  In  a  mild  case  the  patient  may  not 
lapse  into  unconsciousness  but  the  other  symptoms  will 
appear. 

Embolic  cerebral  softening  comes  on  suddenly  like  apoplexy 
from  which  it  is  sometimes  difficult  to  distinguish.  In  some 
cases  there  are  no  premonitory  symptoms.  The  patient 
suddenly  becomes  unconscious  and  upon  awaking  we  find 
hemiplegia,  mental  confusion  and  sometimes  aphasia.  In 
another  class  of  cases  the  attack  begins  in  an  agony  of  fear, 
followed  rapidly  by  mental  confusion,  aphasia,  clonic  spasms 
of  one  or  both  extremities,  rapid  loss  of  motion  and  sensation 
on  one  side,  followed  by  unconsciousness  lasting  fifteen  to 
twenty  minutes.  Upon  awaking  there  is  hemiplegia  and 
aphasia  with  some  mental  confusion.  Such  attacks  may  occur 
several  times  during  the  following  two  or  three  days.  Mild 
cases  in  which  a  small  branch  alone  is  involved  may  present 
the  symptoms  of  thrombosis  but  the  symptoms  come  on 
more  rapidly. 

Blocking  of  particular  vessels  gives  pathognomonic  symp- 
toms. If  a  vessel  on  the  left  side  is  blocked,  aphasia  is  produced. 
The  anterior  cerebral  vessels  are  rarely  attacked  and  they  give 
ill-defined  symptoms,  as  collateral  circulation  is  speedily  es- 
tablished. There  will  be  mental  confusion  and  monoplegia  of 
the  opposite  side,  which  soon  disappears  when  circulation  is 
restored  through  the  collateral  branches.  Blocking  of  the 
middle  cerebral  artery  produces  hemiplegia  and  hemianesthesia. 
The  branches  produce  various  monoplegias  and  those  on  the 
left  side  produce  in  addition  various  forms  of  aphasia.  The 
blocking  of  the  posterior  cerebral  artery  produces  hemianopsia, 
hemiplegia  and  sometimes  hemianesthesia.  That  of  the  basilar 
artery  produces  clonic  spasms,  contracted  pupils,  spasm  of 
muscles  of  deglutition  and  hemiplegia.  In  complete  obstruction 
we  find  paralysis  of  both  sides  with  symptoms  of  bulbar  paralysis. 
Blocking  of  a  vertebral  artery  produces  symptoms  of  acute 
bulbar  paralysis. 


CEREBRAL   SOFTENING  1 97 

The  unconsciousness  which  ushers  in  the  attack  is  seldom 
as  deep  as  coma  and  is  of  short  duration.  The  paralysis  is 
not  complete  and  sometimes  disappears  within  a  few  days,  in 
other  cases  it  persists  through  life.  In  the  thrombotic  form 
there  are  occasional  mild  apoplectiform  attacks,  each  attack 
leaving  the  patient  worse  than  before.  Mental  impairment  is 
marked  and  in  some  cases  there  is  a  rapid  progressive  dementia. 
The  aphasia  is  usually  permanent.  Mental  and  physical 
symptoms  exhibit  at  times  marked  variations,  the  mind  being 
sometimes  quite  clear  while  within  a  few  hours  there  would 
be  mental  confusion  with  loss  of  memory.  In  the  same  manner 
the  paralysis,  aphasia,  coordinating  power,  etc.,  may  change 
within  a  few  hours. 

Diagnosis. — The  differential  diagnosis  between  cerebral  em- 
bolus and  thrombus  depends  upon  the  advent,  the  former  being 
sudden,  the  latter  gradual  and  generally  with  a  preceding 
history  of  cerebral  arteriosclerosis.  In  apoplexy  the  face  is 
congested,  the  coma  is  complete  and  lasts  longer  than  the 
unconsciousness  of  embolism,  there  is  stertor,  and  the  pulse 
is  full  and  slow.  In  embolism  there  is  generally  a  history  of 
rheumatism  or  endocarditis  and  it  comes  on  earlier  in  life 
than  apoplexy. 

Tumor  of  the  brain  may  produce  symptoms  resembling 
thrombus.  There  are,  however,  no  previous  symptoms  of 
arteriosclerosis.  The  advent  is  very  slow,  headache  is  persist- 
ent and  any  slight  excitement  will  aggravate  the  latter  and 
may  produce  spasms  or  unconsciousness.  The  symptoms  are 
those  of  cerebral  compression,  namely,  epileptiform  convulsions, 
choked  disc,  facial  paralysis,  localized  pain,  etc. 

Cerebral  abscess  generally  has  a  history  of  injury  or  disease 
of  the  middle  ear  with  septic  symptoms. 

In  normal  senile  degeneration  there  is  a  gradual  failing  of 
the  mental  powers  but  there  is  no  history  of  unconsciousness, 
paralysis  or  aphasia. 

Prognosis. — The  prognosis  of  cerebral  softening  is  bad. 
While  life  may  be  prolonged  for  years  in  mild  cases,  an  embolus 
in  a  main  artery  may  cause  rapid  and  extensive  degeneration 
and  death  in  a  few  days.  The  same  conditions  which  lead  to 
the  formation  of  one   embolus  or  thrombus  will  lead   to   the 


198  PATHOLOGICAL    OLD   AGE 

formation  of  others  and  several    attacks  usually  destroy  life. 
Mental  impairment  leads  to  dementia. 

Treatment. — The  treatment  is  unsatisfactory  as  the  same 
treatment  which  in  one  case  apparently  helps  may  have  the 
opposite  effect  in  another.  The  first  indication  is  to  maintain 
the  strength  of  the  heart  by  means  of  rapidly  acting  cardiac 
stimulants,  preferably  the  hypodermic  use  of  camphor  and 
ether.  Ammonia  inhalation  should  be  tried  during  the  coma. 
After  the  first  shock  is  past  and  the  patient  emerges  from  the 
coma,  the  further  treatment  depends  upon  his  condition. 
If  there  is  much  irritability  and  mental  confusion  he  must  be 
kept  quiet  by  narcotics.  Cerebral  excitement  must  be  avoided 
but  the  treatment  sometimes  advocated  in  cerebral  embolus 
and  thrombus,  which  is  to  treat  the  case  as  one  of  cerebral 
apoplexy,  is  wrong.  In  apoplexy  there  is  extravasation  of 
blood  with  cerebral  hyperemia  and  compression  and  the  meas- 
ures employed  are  to  diminish  the  flow  of  blood  to  the  brain. 
In  embolus  and  thrombus  we  have  the  opposite  condition. 
There  is  cerebral  anemia  beyond  the  point  of  occlusion,  there 
is  no  compression,  the  face  is  usually  pale  and  the  pupils  are 
unaffected.  The  first  symptoms  of  apoplexy,  embolus  and 
thrombus  are  due  to  shock  and  we  must  look  after  the  heart. 
After  this,  however,  recovery  from  thrombus  depends  upon  the 
rapid  establishment  of  collateral  circulation  and  for  this  purpose 
a  full  supply  of  blood  to  the  brain  is  necessary.  In  these 
cases  powerful  cardiac  stimulants  are  indicated.  We  must 
be  certain  of  our  diagnosis,  however,  for  if  used  in  apoplexy 
they  may  produce  fatal  results.  The  later  treatment  is 
symptomatic,  electricity,  massage  and  passive  motion  to  over- 
come the  paralysis,  and  phosphorus  for  the  mental  impairment. 

CEREBRAL  HEMORRHAGE 

The  frequency  of  apoplexy  in  the  fifth,  sixth  and  seventh 
decades  of  life,  its  sudden  attack  and  the  profound  impression 
upon  the  whole  organism,  mentally  and  physically,  make  it 
perhaps  the  most  readily  recognized  disease  of  old  age.  The 
essential  lesion  is  the  rupture  of  a  miliary  aneurysm  or  of  an 
artery  at  a  point  where  it  has  been  weakened  by  the  athero- 
matous process.     The  break  generally  occurs  in  some  part  of 


CEREBRAL   HEMORRHAGE  1 99 

the  circle  of  Willis  although  it  may  occur  in  any  artery  or 
arteriole  of  the  brain. 

Etiology. — Any  cause  that  produces  arterial  degeneration 
will  also  act  as  a  predisposing  cause  of  apoplexy.  The  most 
prominent  of  these  causes  aside  from  senile  involution  are  alco- 
hol, lead,  mercury,  syphilis,  nephritis,  gout,  anemia,  leukemia, 
and  purpura.  The  exciting  cause  is  usually  some  sudden  strain 
which  increases  the  blood  pressure,  some  intense  mental  excite- 
ment, shock,  alcoholic  stimulation  or  other  cause  that  would 
produce  cerebral  hyperemia.  In  many  cases  a  heavy  meal 
preceded  the  attack. 

Pathology. — The  essential  lesion  in  cerebral  hemorrhage  is 
a  ruptured  vessel,  one  or  more  miliary  aneurysms  or  an  athero- 
matous artery.  The  grave,  often  rapidly  fatal,  attacks  that 
occur  in  senile  cases  are  usually  due  to  the  latter  cause.  The 
clot  from  a  miliary  aneurysm  is  small,  while  from  a  larger 
vessel  it  may  be  the  size  of  a  hen's  egg.  The  nerve  fibers  that 
are  compressed  become  sclerosed  and  degenerated.  If  recovery 
occurs  the  clot  is  not  reabsorbed  but  breaks  down  and  contains 
fatty  granules,  pigment  and  broken-down  brain  matter. 

Symptoms. — Premonitory  symptoms  are  rare  and  occur 
only  if  the  exciting  cause  prevails  for  a  long  time  or  if  there  are 
exciting  causes  not  sufficiently  pronounced  to  cause  rupture. 
In  such  cases  there  are  usually  headache,  vertigo,  thick  speech 
and  tingling  in  one  hand  or  foot.  Occasionally  there  is  some 
impairment  of  the  special  senses,  a  feeling  of  weight  or  heaviness 
and  intense  mental  depression.  There  is  generally  a  momentary 
prodromal  stage  with  terror,  vertigo,  weakness  and  numbness 
on  the  affected  side,  the  patient  tries  to  drag  himself  to  a  seat 
or  corner,  then  falls  insensible  in  a  heap.  The  coma  is  com- 
plete, the  face  is  red  or  cyanosed,  the  breathing  stertorous,  the 
pulse  strong,  full  and  slow,  the  sphincters  are  paralyzed  per- 
mitting evacuation  of  the  bladder  and  intestines.  Hemiplegia 
invariably  results,  in  rare  cases  there  is  a  spasm  or  convulsion. 
The  severity  of  the  disease  is  determined  by  the  severity  of  the 
coma  and  the  extent  of  the  hemiplegia.  In  a  mild  attack  there 
is  stupor  from  which  the  patient  can  be  momentarily  roused 
and  from  which  he  awakes  in  a  few  hours,  his  mind  confused  with 
perhaps  some  aphasia  but  able  to  swallow.  In  this  case  the  arm 
and  leg  may  be  completely  paralyzed  but  the  facial  and  hypo- 


200  PATHOLOGICAL   OLD   AGE 

glossal  nerves  are  but  slightly  affected.  It  is  hardly  necessary 
to  take  up  the  localizing  symptoms  which  would  determine  the 
exact  location  of  the  rupture  and  extravasation  of  blood.  If  the 
hemorrhage  is  into  the  medulla  the  cranial  nerves  are  affected  and 
death  from  interference  with  respiration  and  heart  action  results. 
Hemorrhage  into  a  lateral  ventricle  generally  produces  rigidity 
of  the  opposite  side,  convulsions  and  death.  In  mild  cases  the 
coma  clears  up  after  a  few  hours  leaving  some  mental  confusion, 
aphasia,  headache,  vertigo,  occasionally  some  sensory  impair- 
ment. The  paralysis  also  frequently  clears  up  slowly,  but  the 
affected  parts  rarely  fully  regain  their  power.  In  severe  cases 
it  may  take  two  or  three  days  before  the  mind  is  sufficiently 
clear  to  respond  to  questions  and  even  then  there  may  be  so 
much  mental  confusion  that  the  patient  cannot  answer  intelli- 
gently. Repeated  gaping  is  an  indication  that  the  patient  is 
passing  out  of  the  coma.  After  the  patient  passes  into  a  stage 
of  stupor  he  can  be  roused,  but  immediately  relapses  into  the 
soporous  state,  which  disappears  slowly  and  weeks  may  elapse 
before  he  has  regained  his  intelligence.  Complete  recovery  of 
either  intelligence  or  power  is  rare.  More  often  there  remains 
a  postapoplectic  dementia  in  which  there  is  mental  confusion 
with  depression,  occasionally  fears  and  phobias,  a  dissatisfaction 
with  the  surroundings  and  rage  at  his  impotent  helplessness. 
With  increasing  mental  weakness  the  patient  becomes  apathetic, 
his  interest  in  the  external  world  becomes  less,  but  the  dementia 
does  not  become  complete  and  there  is  usually  more  intelligence 
than  the  dull,  expressionless  countenance  would  indicate. 

There  are  numerous  minor  symptoms  depending  upon  the 
extent  and  location  of  the  extravasation  but  these  do  not  affect 
the  diagnosis  or  treatment. 

Prognosis. — The  prognosis  is  generally  bad,  especially  if 
the  cranial  nerves  are  involved.  A  second  attack  is  almost 
invariably  fatal.  The  principal  source  of  danger  is  in  hypostatic 
congestion  of  the  lungs  and  pulmonary  edema.  Absolute  rest 
is  necessary  to  prevent  a  second  attack  or  further  extravasation 
of  blood  and  this  rest  favors  pulmonary  stasis.  Rapidly  forming 
bed-sores  are  very  unfavorable  signs  and  a  rise  in  temperature 
during  the  coma  is  also  unfavorable.  A  coma  lasting  over 
twenty-four  hours  is  usually  fatal  and  likewise  the  appearance 
of  Cheyne-Stokes  respiration.     A  favorable  diagnosis  can  be 


CEREBRAL   HEMORRHAGE  201 

given  if  the  coma  clears  up  in  a  few  hours  after  the  attack,  and 
if  the  fall  in  temperature  did  not  exceed  2  degrees  and  if  it  does 
not  rise  above  103.  A  hemiplegia  that  does  not  improve  in 
three  or  four  months  will  never  improve. 

Diagnosis. — The  only  diseases  which  might  be  mistaken 
for  apoplexy  are  cerebral  embolus  and  thrombus.  Cerebral  em- 
bolus occurs  at  an  earlier  age,  there  is  generally  a  history  of  rheu- 
matism or  endocarditis  with  valvular  defect,  or  there  may  be 
a  history  of  infarcts  in  other  organs.  The  attack  is  not  as 
severe,  the  coma  not  as  profound,  the  face  is  pale  and  there  are 
generally  clonic  spasms.  In  cerebral  thrombus  the  symptoms 
come  on  more  slowly  and  are  not  as  severe,  the  face  is  pale, 
there  are  no  spasms,  the  symptoms  are  altogether  milder  and 
may  clear  up  completely.  There  is  neither  fever  nor  stertor  in 
cerebral  embolus  or  thrombus.  In  alcohol  narcosis  there  is  the 
odor  of  alcohol,  and  generally  delirium  and  restlessness;  there 
is  no  inequality  of  the  pupils  nor  evidences  of  hemiplegia.  The 
pulse  is  as  in  apoplexy.  We  must  remember  that  apoplexy 
frequently  occurs  after  a  debauch  and  there  may  be  the  odor  of 
liquor  in  addition  to  the  signs  of  apoplexy.  In  this  case  we  may 
find  the  contracted  pupils  of  alcoholism  but  there  is  also  evidence 
of  paralysis,  the  paralyzed  limb  dropping  more  limply  than  the 
other,  the  latter  responding  to  irritation.  Diabetic  and  uremic 
comas  give  a  causative  history,  the  diabetic  coma  is  usually 
preceded  by  dyspnea  or  vomiting  and  there  is  no  paralysis, 
while  in  uremic  coma  if  there  is  paralysis  there  are  generally 
convulsions  preceding  the  coma  or  during  its  progress.  Exami- 
nation of  the  urine  will  clear  up  a  questionable  diagnosis.  Both 
forms  of  coma  begin  in  stupor  and  proceed  to  complete  coma. 
Other  causes  of  coma  as  epilepsy,  opium  poisoning,  cerebral 
concussion  and  compression,  are  readily  distinguished  from  the 
coma  of  apoplexy  by  the  history  and  pathognomonic  signs. 

Treatment. — There  is  no  routine  treatment  for  apoplexy  as 
the  same  method  that  will  avail  in  one  case  will  harm  another. 
Venesection,  highly  praised  by  many  authorities,  is  extremely 
dangerous  in  old  age.  It  may  be  of  service  in  robust,  middle- 
aged  individuals  where  there  is  a  full  bounding  pulse  and  flushed 
face  and  the  certainty  of  correct  diagnosis.  In  aged  persons 
the  withdrawal  of  10  or  15  ounces  of  blood  may  produce  speedy 
collapse  and  death. 


202  PATHOLOGICAL   OLD    AGE 

The  most  important  rule  in  the  treatment  of  apoplexy  ap- 
plies to  the  first  few  minutes  after  the  attack.  Raise  the  pa- 
tient's head  but  do  not  move  him.  More  harm  is  done  by  moving 
the  patient  upstairs  or  to  a  hospital  within  a  few  minutes  after 
the  stroke  than  by  any  subsequent  treatment.  He  should  not 
be  moved  for  at  least  half  an  hour  and  in  the  meantime  ice 
should  be  applied  to  the  head  and  hot  cloths  to  the  feet,  the  ob- 
ject being  to  withdraw  blood  from  the  head  by  producing  a 
local  hyperemia  in  the  lower  extremities.  Involuntary  evacua- 
tion of  the  bladder  and  bowels  generally  occurs  during  the  coma. 
If  this  does  not  occur  the  catheter  and  an  enema  should  be  used. 
During  the  comatose  state  drugs  given  by  the  mouth  are  liable 
to  enter  the  larynx  and  bronchi  and  absorption  by  the  stomach 
is  slow  or  entirely  inhibited.  Whatever  drugs  are  given  during 
this  time  should  be  administered  hypodermically.  In  case  of 
threatened  collapse  camphor  dissolved  in  ether  should  be  given. 
Strychnine  and  digitalin  can  also  be  used  but  nitroglycerin  is 
contraindicated.  If  there  is  a  rapid  full  pulse  aconite  or  vera- 
trin  should  be  used  every  half  hour  until  the  pulse  slows  down 
and  remains  slow.  A  rapid  weak  pulse  indicates  weak  heart 
and  threatened  collapse.  The  most  critical  period  is  during 
the  comatose  stage  and  all  our  efforts  must  be  directed  to  main- 
tain the  strength  of  the  heart  without  increasing  the  cerebral 
hemorrhage.  After  the  comatose  stage  has  passed  and  the 
patient  is  able  to  swallow  the  further  treatment  is  sympto- 
matic. The  one  main  precaution  is  the  avoidance  of  anything 
that  might  produce  cerebral  hyperemia  or  increased  blood  pres- 
sure. After  the  comatose  stage  the  patient  should  be  occasion- 
ally moved  to  prevent  hypostatic  congestion  and  an  air  or  water 
cushion  should  be  provided  to  prevent  bed-sores.  If  there  is 
much  restlessness  morphine  and  bromides  are  indicated.  For 
insomnia,  veronal  is  best.  Phosphorus  is  of  service  if  there  is 
dementia.  For  headache,  frequently  a  distressing  after-effect, 
cold  applications  to  the  head  can  be  tried. 

If  the  facial  paralysis  subsides  within  a  week  we  can  expect 
a  subsidence  of  the  hemiplegia.  If  it  persists  we  have  a  difficult 
problem  to  deal  with.  Under  no  circumstances  should  any 
attempt  be  made  to  massage  or  institute  other  treatment  of  the 
affected  limbs  within  a  week  after  the  attack,  and  even  then 
only  the  mildest  passive  motion  should  be  attempted.     There 


Chronic  Interstitial  Neuritis,  Showing  Degeneration  in  Some 
of  the  Nerve-fibers.  (From  Gordon's  "Nervous  Diseases.")  The 
interstitial  tissue  is  everywhere  increased  and  the  perineurium  thick- 
ened.    The  patient  had  arteriosclerosis. 


Tremorgraph — Post-hemiplegic    tremor.      (Neustaedter,    Med.    Record,    July    17, 

1909.) 


SENILE   NEURITIS  203 

is  always  the  danger  that  rigidity  and  contracture  of  muscles 
will  develop  if  the  paralysis  persists,  and  we  are  sorely  tempted 
to  prevent  this  by  motion,  massage,  electricity  or  other  means, 
but  if  attempted  too  early  there  is  the  greater  danger  of  a  second 
attack.  After  the  second  or  third  week  we  can  begin  with  more 
active  treatment,  using  vibrators,  the  faradic  current  and  mas- 
sage but  voluntary  exercise  should  not  be  permitted  for  several 
weeks,  and  the  patient  should  be  constantly  cautioned  against  at- 
tempting to  walk  or  using  the  arms  until  a  fair  amount  of  power 
has  returned.  During  the  first  week  concentrated  liquid  foods, 
preferably  predigested  or  partly  digested,  should  be  used,  but 
alcohol  must  be  avoided  and  this  eliminates  most  of  the  prepared 
liquid  foods  on  the  market. 

SENILE  NEURITIS 

Senile  neuritis  is  a  form  of  chronic  neuritis  in  which  the 
senile  changes  in  the  nerves  appear  to  be  an  etiological  factor. 
It  may  occur  as  a  localized  or  general  neuritis. 

Etiology. — In  many  cases  an  exciting  cause  can  be  found. 
This  may  be  traumatism,  sudden  temperature  changes,  long 
exposure  to  cold,  extension  of  an  inflammation  from  adjoining 
parts,  diabetes,  alcoholism,  lead  or  mercury  poisoning,  syphilis 
or  other  toxemias.  Where  there  is  a  traumatic  cause,  the  injury 
may  be  no  more  than  a  scratch,  prick  or  bruise.  The  neuritis 
may  then  appear  days  or  weeks  after  the  injury.  Decubitus 
is  often  preceded  by  neuritis.  There  are  many  cases  in  which 
no  exciting  cause  can  be  found  and  aside  from  a  concomitant 
arteriosclerosis  the  only  assignable  cause  is  the  senile  change 
in  the  nerve. 

Pathology. — In  some  cases  no  structural  change  can  be 
found;  in  others  we  find  the  changes  observed  in  the  ordinary 
interstitial  and  parenchymatous  types  of  neuritis.  The  senile 
form  of  neuritis  is  generally  a  polyneuritis  of  the  parenchyma- 
tous type,  the  changes  being  more  marked  at  the  periphery. 
The  axis  cylinder  is  apparently  not  affected  but  there  is  a  hyper- 
plasia of  the  neuroglia.  The  muscle  supplied  by  the  affected 
nerve  undergoes  fatty  degeneration  and  the  vessels  become 
sclerosed. 

Symptoms. — Cases  of  localized  senile  neuritis  are  rare  and 


204  PATHOLOGICAL   OLD    AGE 

the  early  symptoms  are  mild.  There  is  never  the  intense  pain 
associated  with  this  type  of  neuritis  in  earlier  life  or  when  due 
to  other  causes,  though  the  pain  is  constant  and  increased  upon 
pressure.  The  reflexes  are  diminished  but  coordination  is  not 
affected  unless  the  cord  is  involved.  In  some  cases  there  is 
no  marked  motor  or  sensory  impairment  and  the  disease  is 
discovered  accidentally  when  pressing  over  an  affected  nerve 
and  tenderness  is  found.  In  the  multiple  form  of  senile 
neuritis  there  are  motor  and  sensory  disturbances  in  several 
nerves,  generally  in  those  of  the  extremities,  motion  is  di- 
minished but  there  is  never  complete  paralysis  as  occurs  in 
traumatic  neuritis,  paresthesia  especially  pruritus  occurs  but 
there  is  little  or  no  pain  except  upon  pressure.  The  re- 
flexes are  diminished,  the  patellar  reflex  being  usually  lost, 
but  there  are  no  ataxic  symptoms.  In  some  cases  the  mo- 
tor, in  other  cases  the  sensory  manifestations  predominate. 
Twitching  and  tremors  are  rare  and  muscle  atrophy  is  a  late 
occurrence.  The  disease  being  due  to  the  progressive  senile 
degeneration  of  the  nerve,  is  progressive,  but  the  symptoms 
can  often  be  ameliorated. 

Treatment. — If  the  pain  is  severe,  a  hot  pack  or  some  local 
anesthetic  like  cocaine,  chloroform  or  a  mixture  of  chloral  and 
camphor  will  give  temporary  relief.  The  ethyl  chloride  spray 
should  not  be  used,  as  the  intense  cold  produced  may  destroy 
the  surface  capillaries.  The  treatment  of  the  functional  impair- 
ment depends  upon  the  character  of  this  impairment.  If  there 
is  irritability,  hot  baths  and  internally  large  doses  of  bromide 
of  sodium  or  potassium  should  be  used.  Diminished  functional 
activity  requires  stimulation.  Locally  galvanism,  vibration  and 
massage  can  be  employed.  Internally  strychnine  and  arsenic 
should  be  given,  care  being  taken  not  to  overstimulate  the  heart 
and  to  guard  against  the  cumulative  effects  of  the  arsenic. 
When  the  strychnine  is  discontinued,  caffein  or  theobromin 
can  be  substituted. 

SENILE  TRIFACIAL  NEURALGIA 

Trifacial  neuralgia  involving  the  terminal  fibers  of  the  third 
branch  in  the  bony  structure  of  the  lower  maxilla  is  the  only  f orrc 
of  neuralgia  bearing  a  distinct  relation  to  the  senile  processes. 


SENILE    TRIFACIAL   NEURALGIA  205 

Etiology. — This  form  of  neuralgia  affects  the  alveolar  process 
of  the  toothless  lower  jaw  and  is  probably  due  to  compression 
of  the  terminal  fibers  in  the  bony  structure.  It  is  a  compression 
neuritis  rather  than  a  true  neuralgia,  but  the  symptoms  are  those 
of  the  latter.  A  paroxysm  is  produced  when  an  attempt  is  made 
to  crush  a  hard  substance  between  the  jaws,  or  when  the  jaws 
are  forcibly  closed ;  even  simple  pressure  upon  the  jaw  or  the 
presence  of  a  cold  substance  as  ice  may  bring  it  on.  An  attack 
may,  however,  come  on  without  pressure  or  cold  or  any  other 
discernible  cause  and  whether  due  to  pressure  or  any  other 
cause  the  attack  is  identical  in  character  with  an  ordinary 
neuralgic  paroxysm. 

Neuralgia  in  the  other  branches  of  the  trifacial  nerve  as 
well  as  in  other  nerves  may  be  due  to  an  impoverished  con- 
dition of  the  nerve  caused  by  arteriosclerosis.  It  is,  how- 
ever, difficult  to  determine  the  basic  etiological  factor  from 
the  host  of  possible  causative  factors  that  are  generally  present. 
In  some  cases  there  is  no  structural  change  in  the  vessels  or 
nerve  and  no  other  discoverable  cause. 

Symptoms. — The  principal  symptom  of  this  form  of  tri- 
facial neuralgia  is  a  paroxysmal  pain  in  the  lower  jaw,  usually 
localized,  occasionally  occurring  in  several  spots  and  if  brought 
on  by  pressure  the  pain  may  be  some  distance  away  from  the 
spot  pressed  upon.  It  may  be  a  momentary  stitch  or  a  lancinat- 
ing pain  lasting  from  a  few  seconds  to  many  minutes  with  com- 
plete remission  in  the  intervals.  There  are  usually  several  pres- 
sure points  along  the  ridge  of  the  alveolar  process,  besides  the 
usual  one  at  the  orifice  of  the  inferior  maxillary  canal  which, 
when  pressed  upon,  intensify  the  pain.  In  the  intervals  between 
the  attacks  mild  pressure  upon  these  points  does  not  produce 
pain,  but  when  a  certain  degree  of  pressure  is  reached  it  is 
immediately  followed  by  the  agonizing  pain  which  marks  the 
disease. 

Treatment. — In  the  treatment  of  this  form  of  neuralgia  we 
must  try  to  discover  the  basic  etiological  factor.  If  we  find 
;hat  it  is  a  pressure  neuritis  and  is  brought  on  only  by  pressure 
lpon  the  gums,  the  indication  is  plain;  soft  foods  requiring  no 
shewing  must  be  given  and  hard  particles  must  be  avoided  or 
crushed  before  being  eaten.  In  many  cases  the  neuralgic  attacks 
:ome  on  when  pressure  upon  the  gums  is  excluded  and  we  can 


206  PATHOLOGICAL    OLD    AGE 

find  no  other  cause.  In  these  cases  the  treatment  is  purely 
empirical.  If  quick  action  becomes  imperative  a  hypodermic 
injection  of  morphia  and  atropia  should  be  given.  A  2  per 
cent,  cocaine  ointment  made  with  an  animal  fat  base  will  gener- 
ally give  relief.  A  bit  of  cotton  soaked  in  ether  placed  over  the 
pressure  point  is  also  effective  but  the  ethyl  chloride  spray  which 
is  serviceable  in  other  localities  cannot  be  used  in  the  mouth. 
Whatever  local  treatment  is  used  must  be  applied  to  the  gums 
and  this  excludes  many  drugs  which  can  be  used  upon  the  skin. 
The  aconitin  treatment  which  is  almost  a  specific  in  functional 
neuralgias  is  generally  inadmissible  in  senile  cases  on  account 
of  its  depressant  effect  upon  the  heart  and  lungs.  The  combina- 
tion of  aconitin  and  digitalin,  which  has  been  recommended  by 
some  authors,  is  irrational,  as  the  digitalin  which  is  added  to 
overcome  the  depressant  effect  of  the  aconitin  is  slow  in  action, 
while  aconitin  acts  rapidly,  and  may  cause  delirium  cordis  and 
paralysis  of  the  respiratory  muscles  before  the  digitalin  has 
begun  to  act.  If  the  heart  is  in  good  condition  the  aconitin 
may  be  given  in  doses  of  1/300  to  1/200  grain  combined  with 
twice  the  quantity  of  atropia.  Electricity  in  various  forms, 
Roentgen  therapy,  light  therapy,  hydrotherapy,  massage,  vibra- 
tions and  other  non-medicinal  measures  have  been  tried  but 
none  give  the  uniform  results  obtained  from  aconitin.  The 
injection  of  alcohol  has  given  relief  in  some  cases  but  it  is 
intensely  painful  and  the  relief  is  but  temporary.  Surgical 
treatment  is  rarely  indicated  in  this  form  of  neuralgia.  When 
all  other  measures  fail  and  surgical  intervention  becomes 
necessary  the  best  results  are  obtained  from  the  removal  of 
bone  around  the  foramen  by  means  of  the  galvanocautery  or 
by  resection  and  scooping  out  with  a  bone  curette — J  aire's 
operation. 

MODIFIED  DISEASES  OF  OLD  AGE 

The  diseases  of  the  third  group  are  not  senile  diseases,  but 
diseases  which  may  occur  in  earlier  life.  When  occurring  in  the 
aged  they  differ  so  greatly  from  those  of  maturity  that  they  can 
be  differentiated  into  two  separate  diseases.  The  senile  pneu- 
monia differs  in  symptoms,  prognosis  and  treatment  from 
bronchopneumonia,  for  which  it  is  frequently  mistaken.     Senile 


HAY   FEVER  207 

cystitis  differs  from  the  cystitis  of  earlier  life  in  etiology,  path- 
ology and  treatment.  This  group  could  be  made  to  include  every 
disease  occurring  at  both  periods  of  life  for  the  reason  that  the 
senile  degenerative  changes  modify  pathological  processes,  com- 
plicate symptoms,  render  prognosis  more  unfavorable  and 
demand  different  treatment.  When  these  differences  are  clearly 
marked,  especially  when  a  disease  presents  symptoms  that  are 
never  found  in  maturity,  it  is  placed  in  the  third  group.  The 
prefix  senile  is  added  to  these  diseases  and  to  all  diseases  in  which 
it  is  necessary  to  differentiate  between  them  and  similar  dis- 
eases occurring  in  maturity,  such  as  senile  gangrene,  senile 
neuritis,  etc. 

HAY  FEVER 

When  occurring  in  the  aged  this  disease  is  almost  always  car- 
ried over  from  earlier  life.  It  differs  in  some  of  its  cardinal 
symptoms  from  the  disease  in  maturity.  Owing  to  the  increas- 
ing atrophy  of  the  mucous  membrane,  the  coryza  becomes 
milder  year  after  year  and  may  disappear  entirely.  There  is 
usually  an  absence  of  conjunctivitis.  There  is,  however,  a 
dry  irritating  bronchial  catarrh  and  asthmatic  attacks  with 
expiratory  dyspnea,  coming  on  at  night  especially  if  there  is 
much  moisture  in  the  atmosphere.  The  bronchial  symptoms 
increase  as  the  nasal  symptoms  decrease.  There  is  rarely  fever 
or  any  other  of  the  usual  concomitants  of  the  infectious  diseases. 
(In  this  as  in  other  diseases  of  this  group,  the  symptoms  that 
do  not  differ  from  the  symptoms  appearing  in  maturity,  are 
generally  omitted.) 

The  treatment  of  hay  fever  is  prophylactic  and  symptomatic. 
The  prophylactic  treatment  is  the  same  as  in  maturity  and  con- 
sists of  change  of  climate.  Those  who  are  attacked  while  in  the 
lowlands  or  near  the  seashore  will  obtain  relief  in  the  hills  or 
inland  where  there  is  a  dry  atmosphere.  The  reverse  holds  good 
for  those  who  are  affected  when  in  the  highlands  or  inland. 
Every  sufferer  must  determine  for  himself  the  locality  where  he 
is  free  from  attack.  Persons  who  had  remained  away  for  years 
from  the  locality  in  which  they  were  formerly  attacked  will  be 
attacked  again  when  they  return  to  that  place.  Adrenalin  and 
cocaine,  virtually  specifics  in  maturity,  are  useless  and  dangerous 
in  old  age.     The  asthmatic  attack  can  be  relieved  by  chloroform 


208  PATHOLOGICAL   OLD   AGE 

cautiously  inhaled  and  the  internal  administration  of  heroin  in 
i/io-grain  doses. 

SENILE  ASTHMA 

Etiology. — The  term  asthma  is  a  diagnostic  placebo  which 
tells  the  physician  no  more  than  it  does  the  patient;  i.e.,  that 
there  is  a  spasmodic  dyspnea.  It  is  usually  applied  to  bron- 
chial asthma,  a  disease  which  is  rare  in  the  aged,  although 
dyspnea  occurs  frequently  at  that  time  of  life.  Spasmodic 
attacks  may  occur  in  emphysema,  cardiac  disease,  aortic  aneu- 
rysm, dyspepsia,  nephritis,  diabetes  and  various  nervous  condi- 
tions of  the  aged. 

Symptoms. — The  forms  included  under  the  term  senile 
asthma  are  pulmonary  and  cardiac  asthma,  these  being  directly 
due  to  the  senile  processes,  emphysema  and  cardiac  disease  or 
arteriosclerosis  of  the  coronary  artery.  Other  forms  of  asthma 
and  spasmodic  dyspnea  are  readily  distinguished  from  senile 
asthma.  In  bronchial  asthma,  which  is  rare  in  the  aged,  there 
is  generally  a  history  of  attacks  going  back  to  maturity,  there  are 
the  Curschmann's  spirals,  Charcot-Leyden's  crystals,  there  are 
usually  premonitory  symptoms  of  sneezing,  a  tickling  in  the 
throat  extending  to  the  chest,  causing  a  sense  of  irritation  and 
coughing.  In  dyspeptic  or  gastric  asthma  the  Curschmann's 
spirals  and  Charcot-Leyden's  crystals  are  absent,  the  attack 
comes  on  after  a  heavy  meal  and  there  is  inspiratory  and  expir- 
atory dyspnea.  The  dyspnea  of  aortic  aneurysm  is  inspiratory 
and  expiratory,  being  due  to  pressure  upon  the  trachea  or  bron- 
chus, and  it  changes  with  change  of  position.  Other  symptoms 
pointing  to  aneurysm  determine  the  diagnosis.  Hysterical 
asthma  is  rare  in  the  aged  and  there  are  other  symptoms  pointing 
to  hysteria,  while  the  breathing  is  slow  or  irregular.  Spasmodic 
attacks  of  dyspnea  may  occur  in  nephritis,  diabetes  and  various 
nervous  diseases  either  through  the  effect  of  the  disease  upon  the 
heart  and  lungs  or  upon  the  nervous  regulation  of  these  organs. 

In  senile  asthma  the  distinctive  spirals  and  crystals  in  the 
sputum  are  absent  and  there  are  evidences  of  emphysema  or 
cardiac  disease,  usually  both.  In  the  emphysematous  form 
there  is  the  reversal  of  rhythm  and  difficulty  in  expiration, 
while  these  may  be  absent  or  irregular  in  cardiac  asthma.  The 
dyspnea  of  emphysema  comes  on  after  exercise;  in  cardiac 
asthma  the  attack  may  come  on  while  at  rest  and  it  is  accompan- 


PLEURISY  209 

ied  by  palpitation  or  arrhythmia.  This  arrhythmia  may,  how- 
ever, occur  in  emphysematous  asthma,  as  it  follows  exercise  and 
the  heart  is  generally  affected  at  that  period.  Cardiac  asthma 
occurs  occasionally  at  night,  the  patient  awakening  out  of  a 
nightmare  with  a  choking  sensation,  palpitation  and  feeling  that 
he  must  die  from  suffocation.  The  dyspnea  in  senile  asthma 
gradually  becomes  less  severe  and  finally  passes  away  entirely, 
generally  without  cough  or  expectoration. 

The  treatment  of  senile  asthma  depends  upon  the  cause. 
In  the  emphysematous  asthma  immediate  cessation  of  exercise 
and  lying  down  with  the  head  raised  will  usually  give  relief.  If 
the  dyspnea  persists  it  may  be  necessary  to  give  a  hypodermic 
injection  of  morphine  1/8  grain  and  atropine  1/120  grain.  In 
cardiac  asthma  the  cardiac  disease  upon  which  it  depends  must 
be  treated.  During  a  paroxysm  the  inhalation  of  a  nitrite  of 
amyl  pearl  will  usually  give  immediate  relief,  contraindicated, 
however,  if  associated  with  chronic  bronchitis.  The  inhalation 
of  powdered  stramonium,  lobelia  and  other  antispasmodics  are 
useless  and  dangerous  in  either  of  these  conditions.  They  are 
useful  to  relieve  the  paroxysm  of  bronchial  asthma  if  there  is 
no  cardiac  impairment.  Many  remedies  which  are  useful  in 
bronchial  asthma  in  earlier  life  cannot  be  given  to  the  aged  on 
account  of  their  depressing  effect  upon  the  heart.  Chloral, 
antipirin,  pilocarpine,  are  therefore  contraindicated.  Bron- 
chial asthma  usually  lessens  in  severity  with  advancing  age  and 
gives  way  to  the  senile  forms.  If  it  persists  and  emphysema  and 
cardiac  disease  can  be  eliminated,  the  iodides,  preferably  the 
syrup  of  hydriodic  acid  and  bromides  in  large  doses  should  be 
used. 

PLEURISY 

The  pleurisy  of  old  age  differs  in  some  features  from  the 
pleurisy  of  early  life. 

Etiology. — Senile  pleurisy  is  almost  always  a  secondary  dis- 
ease though  the  primary  affection  is  sometimes  so  mild  as  to 
give  no  clearly  defined  symptoms.  In  some  cases  the  primary 
disease  is  latent  until  the  pleurisy  is  recognized  and  it  then  ap- 
pears in  an  active  form,  being  apparently  secondary  to  the 
pleurisy.  It  most  frequently  follows  pneumonia,  especially 
when  the  inflammatory  process  lies  close  to  the  surface.  A 
14 


2IO  PATHOLOGICAL    OLD    AGE 

septic  infection,  either  local  or  general,  may  be  followed  by- 
pleurisy,  and  pulmonary  tuberculosis  in  the  aged  generally 
affects  the  pleura  as  well.  It  may  also  occur  in  typhoid  fever 
and  other  infectious  diseases.  Tumors  and  inflammation  in 
adjacent  tissues  may  produce  inflammation  of  the  pleurae, 
though  these  cases  are  comparatively  rare.  In  some  cases  no 
cause  can  be  found  and  the  exudate  is  sterile.  The  disease  is 
much  milder  than  in  maturity. 

Pathology. — Pleurisy  begins  with  a  fibrinous  exudate  upon 
the  inflamed  site  followed  by  an  exudation  of  serum.  The 
serum  generally  contains  pneumococci,  streptococci  and  staphy- 
lococci, occasionally  tubercle  bacilli,  colon  bacilli,  etc.  The 
septic  organisms  convert  the  clear  serum  into  the  thick,  cloudy, 
purulent  fluid  found  in  empyema.  In  rare  cases,  there  is  a 
hemorrhagic  exudate  following  tuberculosis  or  carcinoma. 
It  may  occur  also  as  the  result  of  traumatism  or  follow  such 
rare  causes  as  the  hemorrhagic  diathesis,  pulmonary  gangrene, 
bursting  of  an  aneurysm,  etc.  The  pseudochylous  or  chyloid 
exudate  occasionally  found  after  tapping  is  due  to  fatty  degener- 
ation of  pus  cells. 

Much  stress  has  been  laid  in  recent  years  upon  cytology  and 
cytodiagnosis  of  pleuritic  effusions.  These  laboratory  adjuncts 
to  diagnosis  are  rarely  required  except  to  furnish  corroborative 
evidence  of  clinical  and  bacteriological  findings.  In  the  cyto- 
logical  examination  the  number  and  character  of  the  polynuclear 
leucocytes,  lymphocytes,  and  endothelial  cells  are  considered. 
In  pneumococcic  pleurisy  there  is  a  polynucleosis,  marked  autol- 
ysis, the  endothelial  cells  are  numerous  at  first  and  later  dimin- 
ished in  number.  Streptococcic  pleurisy  has  a  polynucleosis, 
the  cells  degenerated  and  a  large  number  of  endothelial  cells. 
Tubercular  pleurisy  has  at  first  a  lymphocytosis,  numerous 
eosinophile  cells  and  few  red  cells ;  later  there  is  a  polynucleosis, 
endothelial  cells  few  and  scattered.  Typhoid  pleurisy  has  a 
lymphocytosis  and  endotheliosis,  increased  eosinophiles  and 
many  red  cells.  In  cardiac  pleurisy  there  is  a  marked  endothe- 
liosis and  sometimes  a  polynucleosis.  In  malignant  pleurisy 
portions  of  the  tumor  mass  are  sometimes  found.  These  cyto- 
logical  findings  are  often  valueless,  as  there  are  usually  pneu- 
mococci and  streptococci  present  and  the  cytological  changes 
produced  by  both  are  found. 


PLEURISY  211 

The  anatomical  changes  in  the  pleura  itself  due  to  pleurisy 
are  not  well  marked.  The  senile  pleura  is  normally  thickened 
and  the  surfaces  may  be  adherent  without  having  given  any 
clinical  evidences  of  an  inflammatory  process.  In  senile  pleurisy 
the  surface  may  be  reddened  and  it  appears  swollen  and  rough. 
There  are  frequently  adhesions  but  it  cannot  be  stated  with 
any  certainty  whether  they  are  the  result  of  the  pleurisy  or  are 
old  processes.  There  is  never  an  extensive  exudate  and  the  small 
amount  of  this  with  the  tendency  to  become  fibrinous  would 
favor  the  formation  of  adhesive  bands  and  surface  adhesions. 

Symptoms. — Acute  idiopathic  pleurisy  is  rare  in  the  aged 
and  the  classical  onset  of  this  condition  is  seldom  observed. 
The  slight  chills  which  usher  in  acute  pleurisy  in  earlier  life  are 
usually  absent.  There  may  be  fever  due  to  the  primary  dis- 
ease, but  the  senile  pleurisy  itself  causes  but  slight  if  any  eleva- 
tion of  temperature.  In  some  cases  where  puncture  revealed 
an  empyema  there  was  no  fever.  The  pain  is  usually  slight. 
There  is  occasionally  a  sharp,  momentary  pain  or  "stitch" 
over  the  site  of  the  inflammation,  more  often  there  is  a  dull 
ache  which  becomes  a  sharp  pain  only  when  coughing,  or  taking 
a  forced  deep  breath.  If  the  diaphragmatic  pleura  is  involved, 
the  pain  may  radiate  into  the  abdominal  cavity  and  simulate 
intestinal  colic  or  peritonitis.  Dyspnea  occurs  frequently  owing 
to  the  compression  of  the  lung  by  the  exudate.  This  may  also 
produce  cyanosis  especially  after  exercise.  The  exudate  may 
also  press  upon  the  heart  interfering  with  its  motion,  causing 
arrhythmia  or  palpitation  and  may  produce  such  cardiac  dis- 
turbances as  to  cause  death.  The  respiration  is  shallow,  the 
patient  being  afraid  to  take  a  deep  breath  on  account  of  the 
pain.  During  the  early  stage  of  pleurisy,  before  the  serous 
exudate  has  developed,  there  is  a  dry  painful  cough  without 
expectoration.  This  ceases  as  soon  as  the  exudate  keeps  the 
inflamed  surfaces  apart.  If  there  is  a  cough  with  expectoration 
it  is  due  either  to  bronchitis  or  pneumonia.  An  empyema  may, 
however,  open  into  lung  tissue  and  cause  a  purulent  expectora- 
tion. The  patient  will  bend  toward  the  affected  side  and  when 
lying  down  before  the  serous  exudate  has  appeared,  he  will  lie 
on  the  unaffected  side  so  as  not  to  compress  the  inflamed  pleura. 
After  exudation  he  will  lie  on  the  affected  side,  so  as  to  allow 
full  expansion  of  the  clear  side  of  the  chest. 


212  PATHOLOGICAL   OLD   AGE 

The  physical  signs  are  not  so  clearly  denned  as  in  maturity. 
Owing  to  the  rigid  chest  walls  which  move  as  a  whole,  no  change 
in  movement  can  be  noted  on  the  two  sides  but  there  is  usually 
a  bulging  in  the  intercostal  spaces  of  the  unaffected  side.  As 
there  is  generally  a  senile  emphysema  with  chest  rigidity  the 
percussion  and  auscultation  sounds  are  altered.  The  percussion 
note  is  dull  rather  than  flat  and  the  note  on  the  healthy  side  is 
more  tympanitic  than  usual.  The  affected  side  lies  lower  in  the 
chest  than  the  other  and  may  displace  the  abdominal  viscera 
below  it.  The  auscultatory  sounds  are  not  lost  entirely  as  in 
maturity.  Friction  sounds  before  the  exudate  are  quite  clear 
and  after  the  serous  exudate,  the  vesicular  breathing  becomes 
faint.  Bronchophony  is  found  above  the  level  of  the  fluid. 
The  percussion  and  auscultation  sounds  are  altered  when  the 
level  of  the  fluid  is  changed  by  change  of  position.  When 
the  exudation  is  reabsorbed  or  removed  the  normal  sounds 
are  heard  again,  although  pleuritic  friction  sounds  may  be 
heard  for  months  after  complete  recovery.  The  X-ray  can 
be  employed  in  corroborating  the  diagnosis.  The  symptoms  of 
pleurisy  are  modified  and  may  be  partly  or  completely  masked 
by  the  symptoms  of  the  primary  disease.  The  diagnosis  is 
especially  difficult  if  there  is  a  co-existing  pneumonia  localized 
in  the  lower  part  of  the  lungs.  In  this  case  the  early  symptoms 
are  often  completely  masked  by  the  symptoms  of  the  pneumonia. 
In  some  of  these  cases  the  first  indication  of  pleurisy  is  the  finding 
of  friction  sounds  or  a  pain  on  coughing.  More  often  there  will 
be  no  early  signs  or  symptoms,  and  not  until  the  serous  exudate 
hides  the  rales  of  pneumonia  is  the  presence  of  pleurisy  sus- 
pected. In  many  cases  the  only  positive  means  of  diagnosis 
of  pleurisy  is  an  exploratory  puncture  or  aspiration.  Empyema 
will  generally  give  an  irregular  elevation  of  temperature,  but 
even  this  may  be  absent  in  the  aged,  especially  if  there  is  a  com- 
plicating pneumonia.  Baccelli's  test,  a  whisper  heard  clearly 
in  serous  pleurisy  and  lost  in  hemorrhagic  and  purulent  pleurisy, 
is  fairly  accurate,  nevertheless,  the  only  certain  test  is  the  exu- 
date obtained  by  puncture. 

Treatment. — The  treatment  is  mainly  symptomatic  plus 
the  treatment  of  the  primary  disease.  The  special  indications 
are  the  relief  of  pain,  the  removal  of  the  fluid  by  withdrawal 
through  aspiration  or  resorption,  reduction  of  temperature  and 


PLEURISY  213 

sustaining  the  strength  of  the  patient.  As  the  disease  is  usually 
mild  in  the  aged,  it  is  rarely  necessary  to  do  anything  for  the 
pain  or  temperature.  If  the  pain  is  severe,  local  applications, 
such  as  belladonna  plaster  or  belladonna  ointment,  cocaine 
ointment,  dry  or  moist  heat,  turpentine  stupes,  dry  cups,  etc., 
will  usually  give  relief.  Narcotics  and  analgesics  are  seldom 
required. 

As  the  rise  in  temperature  is  usually  due  to  the  primary  dis- 
ease except  when  empyema  develops,  the  measures  applicable 
in  the  primary  condition  are  indicated.  Quinine  is  the  best 
antipyretic  in  septic  conditions  in  the  aged.  Cold  baths  are 
dangerous  on  account  of  the  shock  and  deficient  reaction  and 
the  coal  tar  products  are  cardiac  depressants. 

The  removal  of  the  exudate  is  the  principal  indication. 
The  most  certain  measure  is  aspiration  but  there  are  several 
dangers  connected  with  this  procedure  in  the  aged.  The  dread 
of  anticipation  followed  by  the  pain  of  the  momentary  puncture 
will  produce  a  shock  causing  an  unfavorable  reaction.  The 
rapid  removal  of  the  fluid  produces  a  partial  vacuum,  and  to  fill 
this  the  lungs  must  expand  rapidly.  As  the  emphysematous 
lung  had  been  compressed  by  the  fluid,  its  rapid  distention 
causes  distention  of  the  alveoli  with  rupture  of  their  walls 
and  an  increase  in  the  emphysema.  The  puncture  site  is 
frequently  the  focus  for  a  septic  or  an  erysipelatous  infection. 
Aspiration  should  be  performed  only  if  other  measures  fail 
and  the  pressure  of  the  effusion  upon  the  heart  or  large  vessels 
causes  serious  interference  with  the  circulation  or  when  the 
pressure  upon  the  lungs  causes  cyanosis  or  distressing  dyspnea. 
The  puncture  is  made  in  the  eighth  or  ninth  intercostal  space 
on  the  scapular  line.  A  small  quantity  of  serum  should  be 
withdrawn  slowly  and  the  opening  rapidly  closed.  In  some 
cases  resorption  is  brought  about  through  the  local  application 
of  cataplasms,  or  tincure  of  iodine,  and  the  internal  adminis- 
tration of  iodide  of  potassium  and  salicylate  of  soda  in  5 -grain 
doses  of  each.  This  should  be  tried  in  every  case  after  the  evi- 
dences of  serous  effusion  appear.  In  empyema  surgical  meas- 
ures are  necessary.  Serum  therapy  has  been  fruitless  in  these 
cases,  resorption  is  impossible  and  it  is  impossible  to  withdraw 
the  pus  completely  by  puncture  and  aspiration. 


214  PATHOLOGICAL    OLD   AGE 


PULMONARY  HYPEREMIA 


Pulmonary  hyperemia  may  be  active  or  passive,  local  or 
general.  The  form  usually  found  in  the  aged  is  passive  hyper- 
emia or  pulmonary  congestion.  Active  pulmonary  hyperemia 
is  rare  in  old  age.  It  is  generally  due  to  direct  irritation  of 
the  lung  through  the  inhalation  of  irritating  vapors  or  gases, 
cold  air,  rarified  or  compressed  air,  violent  coughing,  rapid 
heart  action,  excessive  exercise,  etc.,  or  it  may  occur  as  a 
compensatory  hyperemia  in  a  healthy  part  of  the  lung  when 
the  circulation  is  impaired  in  another  part,  as  happens  in 
pneumonia.  Infectious  diseases  will  sometimes  cause  active 
hyperemia. 

Etiology. — Passive  pulmonary  hyperemia  is  generally  due  to 
diminished  aspiratory  energy  of  the  left  heart,  or  to  mitral  dis- 
ease causing  obstruction  to  the  return  circulation.  These  causes 
will  produce  a  general  congestion.  If  the  patient  is  laid  up  for 
any  length  of  time,  maintaining  a  recumbent  position,  espe- 
cially on  his  back,  the  blood  gravitates  to  the  most  dependent 
portion  of  the  lung  causing  a  hypostatic  congestion.  The  usual 
site  of  hypostatic  congestion  is  the  lower  posterior  portion  of 
the  lung. 

Pathology. — Virchow  first  described  the  congestion  due  to 
mitral  disease.  In  this  form  the  lung  is  heavy,  firm,  of  a  dark 
red  color  dotted  with  yellowish  or  brownish  spots.  The  alveolar 
walls  are  thickened  and  contain  pigment  granules  while  the 
alveoli  themselves  contain  loose  degenerated  and  pigmented 
epithelium  cells.  The  larger  blood-vessels  are  enlarged  and 
engorged,  while  the  capillaries  are  greatly  dilated  and  lengthened 
and  some  may  be  ruptured,  the  blood  extravasating  into  the 
walls  and  interior  of  the  alveoli.  A  brownish  fluid  exudes  from 
the  cut  surface.  This  form  is  called  brown  or  pigment  indura- 
tion. In  hypostatic  congestion  the  lung  is  very  dark  and  heavy, 
with  little  crepitation,  the  tissue  is  friable,  the  aveolar  walls 
are  swollen,  the  alveoli  filled  with  degenerated  cells  and  the 
vessels  are  tortuous,  dilated  and  engorged. 

A  form  of  passive  hyperemia  occurring  with  some  of  the  in- 
fectious diseases  is  splenization,  the  pathological  changes  caus- 
ing a  resemblance  to  spleen  tissue.  The  lung  is  dark  brown 
or  purplish,  while  the  cut  surface  presents  many  reddish  or 


PULMONARY   HYPEREMIA  215 

yellowish  spots  where  blood  had  extravasated  into  the  tissues. 
The  alveolar  walls  are  swollen  but  the  alveoli  may  be  collapsed 
or  filled  with  debris  of  degenerated  epithelial  cells.  There  is 
an  interstitial  edema  which  causes  an  oozing  of  watery  fluid 
from  the  cut  surface.  This  form  of  congestion  is  rare  in  old 
age. 

Symptoms. — The  principal  symptoms  of  pulmonary  con- 
gestion are  dyspnea,  cough  and  expectoration.  These  symp- 
toms may  occur  in  other  pulmonary  diseases  and  it  is  sometimes 
impossible  to  make  a  definite  diagnosis.  Pulmonary  congestion 
is  frequently  found  upon  autopsy,  which  gave  no  symptoms 
during  life  and  in  many  cases  the  first  symptoms  of  an  existing 
congestion  are  the  symptoms  of  a  rapidly  fatal  pulmonary 
edema.  In  acute  hyperemia  the  symptoms  come  on  suddenly 
or  rapidly,  in  passive  hyperemia  they  come  on  slowly,  the  hypo- 
static congestion  existing  sometimes  for  weeks  before  the  dyspnea 
or  cough  becomes  sufficiently  distressing  to  receive  attention. 
In  brown  induration  the  disease  progresses  still  more  slowly. 
The  cough  is  loose  and  produces  little  distress.  The  dyspnea  is 
severe  in  splenization  and  hypostatic  congestion,  but  in  brown 
induration  the  process  of  the  disease  is  so  slow  that  the  patient 
gradually  accustoms  himself  to  the  progressive  diminution  of 
sufficiently  oxygenated  blood.  Physical  exercise  naturally  in- 
creases the  dyspnea.  There  is  no  pain  and  in  some  cases  there 
is  no  distress  other  than  a  feeling  of  tightness,  or  oppression  in 
the  chest.  When  the  disease  is  far  advanced  and  aeration  be- 
comes much  impaired  cyanosis  appears  and  prostration  occurs, 
followed  by  pulmonary  edema  and  death.  The  expectoration 
in  brown  induration  contains  degenerated,  pigmented  alveolar 
cells  but  rarely  blood.  In  the  hypostatic  form  there  are  blood 
streaks  and  spots.  The  expectoration  is  profuse  and  watery, 
differing  from  the  blood-streaked  sputum  of  pneumonia  which  is 
scanty  and  tenaceous.  The  respiration  is  hurried  and  in  hypo- 
static congestion  it  is  confined  to  the  upper  part  of  the  lungs. 

The  physical  signs  are  dulness  upon  percussion  over  the 
affected  area,  moist  rales  and  absence  of  the  vesicular  murmur. 
In  hypostatic  congestion  prolonged  change  of  position  will 
shift  the  location  of  the  congestion  or  cause  it  to  disappear  alto- 
gether, but  it  will  return  upon  prolonged  rest  in  the  original 
position.     The  congestion  in  the  brown  induration  is  permanent. 


2l6  PATHOLOGICAL   OLD   AGE 

The  vesicular  murmur  in  hypostatic  congestion  is  feeble  or  lost 
over  the  affected  area ;  in  brown  induration  the  inspiratory  sound 
is  rough,  while  expiration  is  prolonged.  Rales  appear  with  the 
edema  and  are  really  symptoms  of  pulmonary  edema  (see 
Pulmonary  Edema).  Although  the  symptoms  and  signs  of 
pulmonary  hyperemia  may  occur  in  other  pulmonary  diseases 
the  diagnosis  is  not  difficult.  Absence  of  fever  and  slow  pro- 
gressive onset  distinguish  passive  hyperemia  from  acute  inflam- 
matory conditions.  The  sputum  alone  will  suffice  to  differen- 
tiate it  from  pneumonia.  The  early  stage  of  chronic  interstitial 
pneumonia  gives  similar  symptoms  but  the  history  will  serve  to 
distinguish  between  the  two  diseases. 

Treatment. — The  treatment  depends  upon  the  cause.  In 
hypostatic  congestion  frequent  change  of  position  is  necessary. 
In  all  forms  the  underlying  cardiac  disease  must  be  treated. 
Occasionally  the  Bier  hyperemia  treatment  or  other  measure  for 
producing  local  hyperemia  in  some  other  part  of  the  body  will 
break  up  a  passive  pulmonary  hyperemia,  expectorants  like 
senega,  ipecac,  squills,  are  useful,  but  the  narcotics  are  contra- 
indicated.     Compensatory  hyperemia  requires  no  treatment. 

SENILE  PNEUMONIA 

Faulty  nomenclature,  multiplicity  of  terms,  diverse  views 
as  to  the  etiology  and  pathogenesis  of  pulmonary  inflammation, 
and  as  to  the  interpretation  of  its  signs  and  symptoms  are 
responsible  for  the  confusion  that  exists  relative  to  the  various 
pathological  conditions  included  under  the  term  pneumonia. 
Some  authorities  will  include  under  this  term  only  those  condi- 
tions that  are  due  to  bacterial  activity,  others  include  non- 
bacterial inflammations  of  the  lung.  A  simple  hyperplasia 
without  inflammation  is  called  interstitial  pneumonia  and 
many  writers  call  capillary  bronchitis,  bronchopneumonia 
though  the  lung  tissue  may  not  be  involved.  All  forms 
of  pulmonary  inflammation,  infectious  and  non-infectious, 
may  occur  in  old  age  and  when  occurring  are  modified  by 
the  senile  changes.  (As  the  infectious  forms  are  really 
constitutional  diseases  with  localized  manifestations  they 
will  be  treated  under  the  infectious  diseases  of  the  fifth  group.) 
The  term  senile  pneumonia  is  here  applied  to  a  non-infectious 


SENILE   PNEUMONIA  217 

inflammatory  process  in  the  lung  of  the  aged.  It  may  be  local- 
ized or  diffuse,  primary  or  secondary,  acute  or  chronic,  mild  or 
virulent,  or  latent,  masked  or  abortive.  In  many  cases  a  non- 
infectious pneumonia  becomes  an  infectious  one,  the  diseased 
tissue  being  a  fruitful  field  for  germ  growth  and  development. 

The  primary  senile  pneumonia  is  generally  acute  and  in  most 
cases  rapidly  fatal.  The  secondary  form  is  usually  latent  or 
masked  and  its  existence  is  frequently  not  suspected  until  the 
terminal  edema  sets  in,  or  if  death  is  due  to  another  cause,  its 
presence  is  first  discovered  upon  autopsy.  The  acute  form  is 
generally  virulent,  the  secondary  form  is  usually  mild.  Both 
forms  may  be  localized  or  diffuse,  the  extent  depending  mainly 
upon  the  cause.  Several  localized  areas  may,  by  extension  and 
consolidation,  become  a  single  large  area  of  inflammation. 

Etiology. — Primary  senile  pneumonia  is  generally  due  to 
sudden  temperature  changes  when  the  surface  becomes  chilled 
or  cold  air  is  inhaled.  Loomis  says  nine-tenths  of  all  cases  occur 
between  November  and  May.  Owing  to  the  weakened  heat 
regulation  in  the  aged,  reaction  to  the  sudden  chilling  of  the 
surface  is  neither  rapid  not,  complete  and  the  blood  dammed 
back  from  the  surface  engorges  the  adjoining  viscera.  In  many 
senile  cases  there  is  a  pulmonary  congestion  due  to  valvular 
disease  and  the  sudden  influx  of  blood  converts  the  passive 
hyperemia  into  an  active  inflammation.  When  cold  air  is 
inhaled  an  active  hyperemia  must  be  produced  in  order  to  raise 
the  cold  air  to  the  temperature  of  the  body.  The  usual  effect  of 
the  breathing  of  cold  air  is  a  bronchitis  produced  by  the  frequent 
alternation  of  temperature  of  the  inspired  cold  air  and  the  expired 
warm  air.  The  capillaries  of  the  vesicles  become  alternately 
engorged  and  contracted  and  thus  an  inflammatory  process  is 
instituted.  Noxious  and  irritating  vapors  cause  inflammation 
by  irritating  the  lining  of  the  bronchi  and  vesicles. 

Secondary  senile  pneumonia  generally  follows  a  hypostatic 
congestion  or  brown  induration,  the  passive  hyperemia  being 
converted  into  a  low  inflammatory  process,  through  blood 
changes  occasioned  by  another  disease.  It  may  also  occur 
through  the  extension  of  a  bronchitis  or  pleurisy,  rarely  a 
pericarditis. 

Pathology. — The  usual  pathological  changes  are  such  as 
occur  in  pulmonary  hyperemia,  followed  by  red  hepatization 


3l8  PATHOLOGICAL   OLD    AGE 

of  a  primary  pneumonia.  The  lung  usually  presents  several 
small  or  one  or  two  large  areas  of  surface  hyperemia  and  upon 
section  there  may  be  a  uniform  dark  brown,  smooth,  moist 
surface,  or  if  the  disease  is  diffused  there  will  be  dark  brown 
spots  or  patches.  Under  the  microscope  the  alveoli  appear 
larger,  due  to  the  emphysema  which  is  almost  invariably  present, 
and  the  vesicles  are  filled  with  the  debris  of  degenerated  epithe- 
lial cells,  mucus,  blood  cells  or  blood  pigment  and  sometimes 
fibrin.  The  capillaries  are  enlarged  and  engorged  and  some  may 
be  ruptured.  There  is  sometimes  an  interstitial  edema  and  it  is 
often  difficult  to  determine  whether  there  is  an  inflammatory 
process  or  a  purely  mechanical  hyperemia  with  edema.  In 
senile  cases  presenting  no  pulmonary  symptoms  until  the  ter- 
minal edema,  it  is  generally  impossible  to  differentiate  between 
senile  pneumonia  and  hyperemia  with  edema.  The  presence  of 
fibrin  in  the  alveoli,  found  at  autopsy,  always  indicates  an  inflam- 
matory process. 

Symptoms. — Senile  pneumonia  generally  begins  with  symp- 
toms so  mild  that  they  are  not  noticed  until  the  disease  is  far 
advanced.  A  distinct  chill  and  fever  indicate  infection.  In 
primary  senile  pneumonia  there  may  be  a  sensation  of  chilliness 
after  exposure,  the  patient  feeling  that  he  cannot  get  warm, 
that  he  feels  cold  all  through.  This  is  followed  by  malaise, 
languor,  and  uneasiness,  the  patient  says  he  does  not  feel  well 
yet  cannot  assign  the  discomfort  to  any  locality.  He  may  say 
he  has  not  slept  well  and  is  disinclined  to  leave  the  bed.  After 
a  day  or  two  of  such  vague  sensations  there  may  be  a  slight 
fever,  headache,  dyspnea,  the  breathing  becomes  shallow  and 
rapid,  a  cough  with  little  mucous  expectoration  follows,  or  an 
existing  bronchitis  is  aggravated.  There  is  no  pain  but  an 
oppressive  feeling  in  the  chest,  the  patient  frequently  striking 
his  chest  as  though  to  dislodge  some  mucus.  He  becomes 
rapidly  weaker  and  dies  from  exhaustion.  In  other  cases 
cerebral  symptoms  appear  after  the  second  or  third  day  and  the 
patient  has  a  low  muttering  delirium  which  the  family  mistakes 
for  talking  in  his  sleep.  In  some  cases  pulmonary  edema  sets  in; 
this  occurs  generally  in  secondary  senile  pneumonia  following 
another  disease  (not  secondary  through  extension  of  an  adjoin- 
ing inflammation  but  through  blood  changes) .  In  another  set 
of  cases  the  disease  begins  with  rapid  prostration  followed  by 


SENILE    PNEUMONIA 


219 


the  pulmonary  symptons  of  rapid,  shallow  breathing,  dyspnea, 
a  distressing  cough  and  a  tenacious  mucous  expectoration.  A 
pneumonia  following  a  bronchitis,  pleurisy  or  pericarditis 
begins  with  a  marked  rise  in  temperature,  while  if  secondary  to 
a  disease  producing  blood  changes  the  symptoms  may  be  latent 
or  masked  by  the  more  pronounced  symptoms  of  the  primary 
disease.  The  symptoms  common  to  all  forms  of  senile  pneu- 
monia are  prostration,  rapid  shallow  breathing  and  cough. 
The  dyspnea  may  not  be  pronounced,  as  in  his  exhausted  con- 
dition the  patient  will  not  make  the  powerful  efforts  to  get  air 
and  there  will  be  cyanosis  instead.  Striking  the  chest  appar- 
ently to  dislodge  mucus  occurs  generally  when  the  air  vesicles 
become  filled  with  mucus  or  other  material.  The  expectoration 
may  be  blood-streaked  when  a  powerful  effort  is  made  to  bring 
up  the  mucus  and  a  capillary  is  ruptured  by  the  strain  of  cough- 
ing. While  primary  senile  pneumonia,  occurring  when  the 
patient  was  healthy,  gives  early  symptoms  of  pulmonary  disorder, 
secondary  senile  pneumonia  may  give  no  clear  symptoms  at 
any  time.  An  increase  in  temperature  during  an  acute  disease 
points  to  some  complication;  an  increase  in  the  rate  of  respira- 
tion during  the  course  of  an  acute  or  chronic  disease  points  to 
pneumonia.  The  respiration  is  usually  so  shallow  that,  unless 
there  is  an  accompanying  dyspnea,  attention  is  not  attracted 
to  it.  The  neglect  to  count  the  respirations  is  responsible  for  many 
errors  in  the  diagnosis  where  pneumonia  is  present.  In  hypo- 
static pneumonia  following  hypostatic  congestion,  the  lower  por- 
tion of  the  lung  is  affected  and  the  physical  signs  are  found  over 
the  posterior  lower  portion  of  the  lung.  Where  scattered  areas 
are  involved,  the  physical  signs  can  often  be  found  at  the  apex, 
in  the  interscapular  space  and  in  the  infraclavicular  spaces  and 
1  occasionally  at  the  sides.  There  is  percussion  dulness  over 
the  affected  areas,  adjoining  tympanitic  areas,  and  fine  crepitant 
rales  are  heard  at  the  end  of  inspiration  and  beginning  of  expira- 
tion. The  expiration  is  prolonged.  The  respiratory  sounds 
are  diminished  and  vocal  fremitus  may  be  increased.  The 
percussion  note  may  be  altered  if  there  is  a  portion  of  emphy- 
sematous lung  over  the  inflamed  area,  the  fine  rales  may  be 
masked  by  the  coarser  rales  of  bronchitis  or  by  the  friction 
sounds  of  pleurisy  or  pericarditis. 

In  differentiating  between  senile  pneumonia  and  other  con- 


2  20  PATHOLOGICAL   OLD   AGE 

ditions  we  have  no  pathognomonic  sign,  no  symptom  complex 
to  guide  us  and  it  is  often  necessary  to  make  our  diagnosis  by 
exclusion.  Acute  inflammations  can  generally  be  excluded  by 
the  absence  of  fever,  or  initial  chill.  The  infectious  pneu- 
monias can  be  excluded  by  the  absence  of  high  temperature  and 
pathogenic  germs  in  the  sputum.  Tuberculosis  is  slow,  there  is 
not  the  rapid  prostration,  it  responds  to  the  tuberculin  test  and 
the  bacilli  are  found  in  the  sputum.  Influenza  has  marked 
initial  symptoms,  fever,  mucous  inflammation,  conjunctivitis 
and  presents  pathogenic  germs.  Pleurisy  with  effusion  gives 
percussion  flatness  with  change  of  level  when  the  position  is 
changed,  the  intercostal  spaces  bulge,  no  respiratory  sounds  are 
heard  through  the  effusion,  the  cough  is  distressing  and  there 
is  not  the  feeling  of  irritating  mucus  which  induces  the  pneu- 
monic patient  to  strike  his  chest  in  an  effort  to  dislodge  it.  The 
secondary  pneumonia  following  pleurisy,  is  either  a  hypostatic 
pneumonia  giving  no  symptoms  until  edema  sets  in,  or  an 
infection  with  rapid  rise  of  temperature.  Capillary  bronchitis 
or  bronchiolitis  gives  no  percussion  dulness,  expiration  is  not 
prolonged,  there  is  not  the  profound  or  rapid  prostration  and 
the  rales  may  disappear  for  a  time  after  expectoration.  If 
pneumonia  follows  a  bronchitis  the  temperature  is  suddenly 
raised,  the  cough  is  more  severe,  expectoration  is  scantier,  the 
respiration  is  hurried  and  shallow,  there  may  be  dyspnea  and 
cyanosis  and  rapid  prostration.  In  all  cases  of  secondary 
senile  pneumonia  a  rapid  increase  in  the  gravity  of  the  primary 
disease  with  increased  temperature,  prostration  and  shallow, 
rapid  breathing  indicates  a  pneumonic  complication. 

Latent  pneumonia  may  exist  as  a  primary  disease  without 
giving  any  symptoms  and  the  patient  expires  suddenly  while 
apparently  in  perfect  health,  or  there  may  be  vague  symptoms  of 
malaise  and  weakness  lasting  several  days  when  pulmonary 
edema  suddenly  develops  and  is  rapidly  fatal.  This  form  of 
pneumonia  occurs  frequently  in  senile  dements  whose  weakened 
mental  powers  are  unable  to  comprehend  the  urgent  symptoms. 

Inhalation,  aspiration  and  deglutition  pneumonias,  generally 
classed  as  bronchopneumonia,  are  due  to  the  inhalation  oi 
noxious  or  irritating  vapors  or  to  the  lodgement  of  a  foreigr 
body  in  the  trachea  or  bronchi.  The  symptoms  of  deglutitior 
pneumonia  are  localized  to  the  part  in  which  the  foreign  bod} 


SENILE   PNEUMONIA  221 

is  lodged  and  later  to  the  part  of  the  lung  supplied  by  the 
branches  of  the  bronchus  which  is  blocked.  The  inhalation  pneu- 
monia is  a  diffuse  pneumonia  from  the  onset.  These  forms  of 
pneumonia  are  rare  in  the  aged  and  when  occurring  give  pro- 
nounced symptoms  of  primary  senile  pneumonia  with  intense 
dyspnea  and  rapid  prostration.  They  begin  as  a  non-infectious 
inflammation  but  infection  soon  sets  in. 

Treatment. — The  principal  indication  in  the  treatment  of  senile 
pneumonia  is  the  prevention  of  the  fatal  complications  of  gen- 
eral exhaustion,  cardiac  exhaustion,  hypostatic  congestion  and 
edema  and  cerebral  complications.  The  most  frequent  cause 
of  death  is  cardiac  exhaustion  and  this  is  often  traceable  to 
the  injudicious  use  of  cardiac  stimulants.  When  the  heart 
is  working  near  the  limit  of  its  functional  capacity  further 
stimulation  will  suddenly  paralyze  or  rapidly  exhaust  that 
organ.  Cardiac  stimulants  should  never  be  given  in  pneu- 
monia before  the  heart  becomes  weak.  Cardiac  therapy  in 
pneumonia  follows  the  general  rule  for  cardiac  therapy  in 
other  conditions.  A  full  rapid  pulse  requires  cardiac  depres- 
sants like  aconite,  veratrum  and  gelsemium  cautiously  admin- 
istered. The  coal  tar  depressants  should  never  be  given.  A 
weak  rapid  pulse  requires  heart  tonics  like  digitalis,  stro- 
phanthus,  coffee  or  cactus.  A  weak  slow  pulse  requires  spar- 
tein  or  strychnine.  A  full  slow  pulse  requires  the  nitrites. 
Emergency  drugs  in  threatened  heart  failure  are  strychnine, 
ether,  camphor,  the  combination  of  strychnine,  nitroglycerin 
and  digitalin  used  hypodermically  and  alcohol  or  ammonia 
carbonate  internally.  In  senile  pneumonia  the  heart  is  weak 
from  the  start  and  mild  cardiac  stimulants  like  caflein  or  cactin 
can  be  given.  As  soon  as  heart  failure  is  threatened,  the  more 
powerful  stimulants  are  required.  Digitalis  should  not  be 
given,  as  on  account  of  its  powerful  vasoconstrictor  effect, 
the  blood  supply  to  the  lungs  is  still  further  diminished.  The 
rapid  prostration  is  best  combated  by  concentrated  food, 
alcohol,  strychnine,  arsenic  and  phosphorus.  The  strychnine 
and  arsenic  can  be  combined  as  arsenate  of  strychnine  given 
in  doses  of  i/ioo  grain.  Phosphorus  should  not  be  used  until 
there  is  marked  exhaustion  when  it  can  be  given  in  doses  of  i/ioo 
grain  of  the  ordinary  yellow  phosphorus  or  2  grains  of  the  amor- 
phous red  phosphorus. 


222  PATHOLOGICAL   OLD   AGE 

Frequent  percussion  is  necessary  to  determine  the  presence  of 
hypostatic  congestion.  The  treatment  is  repeated  change  of 
position. 

Cerebral  symptoms  may  be  due  to  high  temperature, 
toxemia,  disturbed  cerebral  circulation  or  deficient  oxygenation 
of  blood,  the  last  being  the  usual  cause  in  senile  pneumonia. 
High  fever  does  not  occur  in  senile  pneumonia,  and  the  only 
toxemias  aside  from  pathogenic  bacterial  toxins  that  may  occur 
are  autointoxications  from  the  absorption  of  the  products  of 
intestinal  decomposition  or  from  retention  of  urea.  Carbonic 
oxide  intoxication,  due  to  incomplete  aeration,  is  evidenced  by 
cyanosis.  Respiratory  stimulants  are  required,  the  most  power- 
ful being  atropine.  It  can  be  given  in  doses  of  1/120  grain.  If 
there  is  a  sallow  cyanosis  beginning  with  a  pale  face,  nitro- 
glycerin hypodermically  or  nitrite  of  soda  by  mouth  should  be 
added  to  the  atropine.  If  there  is  a  purplish  cyanosis  beginning 
with  a  flushed  face,  the  atropine  should  be  given  alone.  Oxygen 
is  of  temporary  utility  in  relieving  the  cyanosis  and  cerebral 
symptoms  but  it  does  not  influence  the  inflammatory  process. 
Urea  intoxication  is  infrequent  in  senile  pneumonia.  The  treat- 
ment of  it  consists  in  renal  stimulation  by  vegetable  diuretics. 
If  rapid  action  is  required,  as  in  threatened  uremia — a  rare 
contingency  in  senile  pneumonia — the  nitrate  of  soda  or  potash 
should  be  used  in  5 -grain  doses  every  three  hours.  For  intes- 
tinal autointoxication  the  proper  remedies  are  active  cathartics 
and  intestinal  antiseptics,  pieferably  salol  and  the  sulphocar- 
bolates.  There  is  no  specific  treatment  for  senile  pneumonia. 
In  some  cases  a  hyperemia  produced  in  some  other  portion  of 
the  body  will  relieve  the  pulmonary  congestion.  This  can  be 
done  by  hot  foot  baths,  hot  cataplasms  applied  to  the  chest  or 
back  or  dry  cups.  These  measures  may  avail  in  the  beginning 
of  the  disease  but  not  later.  In  ordinary  cases  none  of  the  symp- 
toms, except  perhaps  the  cough  and  difficult  expectoration, 
are  distressing  enough  to  attract  the  attention  of  the  patient. 
There  is  rarely  any  pain  but  there  may  be  a  feeling  of  tightness 
or  oppression  in  the  chest.  This  may  sometimes  be  relieved 
by  hot  poultices.  Narcotics,  especially  the  opiates,  should  not 
be  given  in  this  disease.  If  there  is  a  distressing  cough  with 
little  expectoration  we  can  use  equal  parts  of  the  syrup  of  the 
hypophosphite  of  ammonium,   syrup  of  senega  and   syrup  of 


SENILE  ACUTE  GASTRITIS  223 

ipecac  in  teaspoonful  doses.  The  inhalation  of  a  solution  of 
menthol  in  eucalyptol  will  stimulate  the  secretion  from  the 
mucous  membrane  of  the  bronchial  tubes.  For  the  dyspnea 
we  can  use  a  combination  of  atropine  and  strychnine,  using 
1/120  grain  of  atropine  and  1/120  grain  of  strychnine.  It  can 
be  given  by  mouth  or  hypodermically.  Dyspnea  is,  however, 
rarely  severe  enough  to  require  treatment.  For  insomnia  we 
can  use  veronal,  proponal  or  urethane.  The  carbamide  group 
of  hypnotics  is  safer  than  the  methane  group  where  there  is  im- 
paired aeration  of  blood. 

Hygienic  regulations  are  of  the  greatest  importance  in  senile 
pneumonia.  Fresh  dry  air,  sunshine,  a  temperature  between 
700  and  7  50,  no  draughts,  are  imperative.  A  cheerful  companion 
has  a  beneficial  effect.  There  should  be  a  daily  evacuation  of 
the  bowels  and  the  quantity  of  urine  and  urea  passed  daily 
should  be  noted.  During  the  height  of  the  disease  we  can  use 
the  liquid  predigested  foods  in  addition  to  simple  carbohydrates 
but  no  meat.  If  convalescence  occurs  the  patient  should  be 
instructed  to  take  deep  breaths  even  if  they  do  cause  spells  of 
coughing.  Warm  clothing  must  be  worn  for  months  after 
recovery. 

SENILE  ACUTE  GASTRITIS 

This  is  the  disease  known  to  the  layman  as  acute  indigestion 
and  is  a  frequent  cause  of  death  in  the  aged.  It  is  due  to  an  irri- 
tation of  the  degenerated  stomach,  generally  caused  by  some 
dietetic  error. 

Etiology. — We  must  remember  that  the  senile  stomach  has 
atrophied  walls,  there  is  a  waste  of  the  glandular  element,  and 
usually  dilatation,  which  is  more  pronounced  in  beer  drinkers 
and  in  those  who  habitually  take  too  much  food.  There  is  a 
chronic  gastric  catarrh  with  slow  digestion  and  abnormal  fer- 
mentation. In  this  condition,  causes  too  slight  to  be  of  any 
deleterious  effect  in  the  normal  stomach  of  maturity  will  have 
grave  results  in  the  aged.  The  most  frequent  cause  is  over- 
sating,  especially  while  the  stomach  is  still  partly  filled  with 
:ood  which  is  in  the  process  of  active  fermentation.  This 
accounts  for  the  many  cases  of  acute  gastritis  during  banquets 
tfhen  food  is  taken  shortly  after  the  regular  meal.     In  some 


2  24  PATHOLOGICAL   OLD   AGE 

cases  the  cause  can  be  traced  to  the  ingestion  of  partly  decom- 
posed food,  especially  cold  storage,  canned  and  chemically  pre- 
served food. 

Pathology. — The  mucous  membrane  of  the  stomach  is  red- 
dened but  there  is  never  the  intense  congestion  found  in  the  same 
disease  of  maturity.  Swelling  of  the  membrane  is  rare  but 
erosions  are  frequently  observed.  The  secretion  of  mucus  is 
diminished  owing  to  the  waste  of  the  mucous  glands.  The 
presence  of  a  large  quantity  of  mucus  in  the  vomitus  indicates 
that  some  intense  irritant  to  the  glands  has  stimulated  them 
to  abnormal  activity.  The  stomach  is  distended  with  food  and 
gas,  pressing  upward  when  the  patient  is  erect,  and  bulging 
outward  when  he  is  lying  down. 

Symptoms. — The  earliest  symptoms  are  usually  a  feeling  of 
distress  and  heaviness  in  the  stomach  with  eructation  of  gas. 
Sometimes  the  pressure  upon  the  diaphragm  produces  singultus, 
more  often  it  causes  gastric  asthma  through  interference  with 
cardiac  action,  and  we  have  then  symptoms  of  cardiac  irritation, 
palpitation  of  the  heart,  weak,  irregular  pulse,  dyspnea,  vertigo, 
faintness  and  pallor.  If  the  face  is  flushed  there  is  danger  of 
apoplexy.  Vomiting  may  occur,  although  it  is  rare  in  old  age. 
The  eructation  of  gas  gives  temporary  relief  and  if  vomiting 
occurs  the  relief  is  more  permanent. 

Treatment. — The  greatest  danger  from  this  form  of  gastritis 
is  cardiac  irritation;  secondary  dangers  arise  from  prostration 
and  from  the  direct  injury  to  the  gastric  walls.  The  first  danger 
is  temporarily  removed  by  putting  the  patient  upon  his  back, 
thereby  relieving  the  pressure  upon  the  heart  from  below 
After  a  few  minutes  the  patient  can  be  placed  in  a  semirecumbent 
position  and  pressure  can  be  made  over  the  stomach  to  dislodge 
the  gas.  It  is  a  mistake  to  prevent  eructations.  The  patient 
attempts  to  suppress  this,  owing  to  his  mistaken  sense  of  pro- 
priety, but  the  physician  who  attempts  to  prevent  it  is  guilty  of 
the  grossest  ignorance.  The  rational  treatment  in  these  cases  is 
to  empty  the  stomach  as  soon  as  possible.  Where  the  stomach  is 
overfilled,  emetics  will  have  little  effect  unless  given  in  such  large 
doses  as  to  injure  the  walls  of  the  stomach.  The  senile  stomach 
is  less  sensitive  to  gastric  irritants  and  the  emetic  mixing  with 
the  mass  of  food  either  loses  its  action  or  the  action  is  slowed 
and  prolonged.     The  most  rapid  and  reliable  emesis  in  these 


SIMPLE   CHRONIC   GASTRITIS  225 

cases  is  produced  by  a  hypodermic  of  i/io  grain  of  apomorphine. 
This  should  be  combined  with  1/2  grain  of  caffeine  if  the  heart 
is  weak.  If  vomiting  occurs  while  the  patient  is  unconscious 
he  should  be  placed  upon  his  side  or  almost  upon  his  face  with 
the  head  lowered  to  prevent  aspiration  of  vomited  matter.  The 
strain  of  vomiting  may  be  severe  enough  to  produce  prostration. 
In  this  case  we  can  give  strong  black  coffee  or  champagne 
or  some  other  alcoholic  stimulant  greatly  diluted.  In  an  emer- 
gency where  there  is  danger  of  death  from  exhaustion  we  must 
resort  to  the  more  powerful  drugs  like  strychnine,  digitalin, 
camphor,  etc.,  given  hypodermically.  A  localized  pain  after 
an  acute  attack  indicates  an  erosion  which  may  develop  into 
an  ulcer  or  may  be  the  focus  for  a  carcinoma.  If  such  pain 
exists  the  subnitrate  of  bismuth  in  5 -grain  doses  is  indicated  and 
if  the  pain  is  severe  or  there  is  persistent  nausea  we  can  add 
cocaine  in  1/8-grain  doses.  If  the  gastric  attack  is  mild,  vomit- 
ing should  be  induced  by  irritating  the  fauces  or  by  giving  1 5  or 
20  minims  of  the  fluid  extract  of  ipecac,  mustard,  or  salt 
water  or  any  other  handy  emetic.  The  same  measure  should 
be  taken  if  an  acute  attack  is  due  to  decomposing  food.  After 
some  relief  has  been  obtained  a  vegetable  cathartic  should  be 
given  combined  with  the  bile  salts.  Occasional  massage  over 
the  fundus  may  be  necessary  to  secure  dislodgment  of  food  that 
may  be  lying  in  the  pouch  as  the  flaccid  walls  of  the  stomach 
might  permit  a  sinking  of  the  fundus  below  the  pyloric  orifice. 
No  food  should  be  taken  for  several  hours  after  the  stomach  has 
been  emptied. 

Simple  Chronic  Gastritis 

Etiology. — Simple  chronic  gastritis  is  generally  due  either 
to  repeated  attacks  of  acute  gastritis  or  to  the  constant  irritation 
of  the  stomach  by  improper  food  or  drink.  It  may  also  occur  in 
gastric  ulcer  or  cancer,  in  diseases  which  cause  local  passive 
hyperemia,  in  diseases  of  the  liver  with  impaired  portal  circula- 
tion, in  heart  disease,  and  in  some  constitutional  diseases  as  dia- 
betes, gout,  anemia,  tuberculosis,  etc. 

Pathology. — The  walls  are  usually  thickened,  the  mucous 
membrane  is  pale  and  covered  with  a  thick  layer  of  mucus. 
If  there  is  passive  hyperemia  the  veins  become  dilated  and 
is 


2  26  PATHOLOGICAL    OLD    AGE 

are  prominent.  The  glands  are  sacculated  and  may  form  cysts 
if  their  openings  are  blocked.  Late  in  the  disease,  the  walls 
grow  thin,  but  shrinking  of  the  organ  which  occurs  frequently 
in  maturity  does  not  occur  in  the  aged. 

Symptoms. — The  symptoms  of  chronic  gastritis  are  the 
same  as  those  of  acute  gastritis,  but  milder  and  more  persistent. 
There  is  a  constant  sense  of  discomfort  about  the  stomach  more 
pronounced  when  food  is  taken.  Morning  nausea  and  retching 
occur  and  bile-stained  mucus  may  be  vomited.  In  some  cases 
food  is  vomited  after  every  meal  and  (if  this  occurs)  several  hours 
later  the  vomited  material  has  a  sour  odor  from  acid  fermen- 
tation. Constipation,  intestinal  colic,  palpitation  of  the  heart 
and  psychic  depression  are  usual  secondary  symptoms. 

Treatment. — The  treatment  which  is  dietetic,  hygienic  and 
medicinal  should  follow  the  lines  laid  down  for  senile  gastric 
catarrh;  alcoholics  should,  however,  be  forbidden.  If  it  is 
secondary  to  another  disease  the  cure  may  depend  upon  the 
treatment  of  the  primary  disease. 

SENILE  DIARRHEA 

Etiology. — Diarrhea  occurring  in  the  aged  is  generally  due 
to  the  faulty  character,  too  great  frequency  or  excessive  amount 
of  food  taken.  Owing  to  the  senile  changes  in  the  stomach 
and  intestines  with  diminished  metabolic  activity,  a  smaller 
amount  of  food  is  assimilated.  If  the  appetite  is  not  diminished 
and  as  much  food  is  taken  as  during  maturity,  the  demands  on 
the  stomach  and  intestines  become  excessive  and  frequent  stools 
result.  In  some  cases  food  passes  unchanged  into  the  intestines 
and  may  pass  out  unchanged  causing  senile  lientery.  Diarrhea 
may  occur  as  a  symptom  of  inflammatory  or  ulcerative  condi- 
tions of  the  bowel  but  these  can  be  readily  distinguished  from 
the  simple  chronic  diarrhea  of  the  aged.     (See  Enteritis.) 

Symptoms. — Senile  diarrhea  comes  on  slowly,  the  patient 
becoming  gradually  accustomed  to  two  or  three  stools  a  day. 
If  the  amount  of  food  is  not  diminished  the  number  of  stools 
or  the  quantity  of  the  feces  will  be  increased.  The  stools  may 
be  normal  in  color  and  consistency  or  they  may  be  lighter  and 
thinner  than  normal  but  they  are  never  fluid.  There  is  no  pain 
or  tenesmus  and  aside  from  the  frequency  of  the  stools  there 


SENILE   DIARRHEA  227 

is  no  discomfort.  They  contain  little  or  no  mucus  and  no 
blood. 

Catarrhal  diarrhea  is  infrequent  in  the  aged  as  the  mucous 
membrane  is  atrophied,  and  its  secretion  diminished  and  it 
requires  a  violent  irritation  to  produce  an  enteritis  with  mucous 
discharges.  In  this  form  of  diarrhea  there  is  some  mucus 
in  or  surrounding  the  stool  mass  and  when  due  to  an  acute 
inflammation  or  ulceration  there  is  usually  blood,  and  occasion- 
ally pus. 

Serous  diarrhea,  due  to  intestinal  irritation  from  undigested 
food  is  a  watery,  brown,  offensive  discharge  which  irritates  the 
anus,  and  if  it  passes  through  impacted  feces,  it  breaks  off 
portions  which  come  away  in  scales. 

Nervous  diarrhea  is  due  to  strong  emotion  and  stools  first 
normal  are  followed  by  a  watery  discharge. 

The  diarrhea  of  chronic  intestinal  catarrh  is  a  mucous  diarrhea 
generally  with  pain  and  borborygmi.  The  stools  are  not  fre- 
quent, often  not  exceeding  one  daily,  and  they  are  sometimes 
of    normal    appearance,    sometimes    watery.     (See    Enteritis.) 

The  diarrhea  of  simple  ulcerative  colitis  contains  particles  of 
undigested  food  and  occasionally  blood,  the  diarrhea  alternates 
with  constipation  and  there  is  pain  or  an  uncomfortable  feel- 
ing in  the  lower  part  of  the  bowel,  besides  loss  of  strength,  emacia- 
tion, cachexia,  etc.  It  occurs  most  frequently  in  men  past  mid- 
dle age. 

In  all  ulcerative  and  inflammatory  diarrheas  the  lessened 
intake  of  food  will  diminish  the  amount,  but  will  not  alter  the 
character  of  the  stool.  Intestinal  parasites  may  cause  diar- 
rhea but  these  generally  give  symptoms  pointing  to  their  pres- 
ence. In  all  cases  of  diarrhea  an  examination  of  the  stools  is 
necessary  to  determine  the  presence  or  absence  of  blood,  mucus, 
pus,  undigested  food,  shreds  of  tissue,  and  parasites. 

Treatment. — The  first  indication  in  the  treatment  of  senile 
diarrhea  is  to  regulate  the  food,  diminishing  the  quantity  and 
frequency.  Food  should  not  be  given  oftener  than  in  five-hour 
intervals.  If  there  is  lientery,  the  character  of  the  undigested 
food  should  be  determined  and  if  possible  the  digestant  of  that 
form  should  be  supplied  or  that  variety  of  food  withdrawn. 
Light  colored  and  offensive  smelling  stools  require  the  bile  salts. 
In   some   cases   a   senile   diarrhea   can   be   cured  by  giving  a 


2  28  PATHOLOGICAL   OLD    AGE 

saline  cathartic  followed  by  a  day's  starvation.  This  should 
be  the  routine  treatment  of  every  case  and  the  further  treat- 
ment regulated  by  the  result.  If  the  diarrhea  persists  bismuth 
subcarbonate  should  be  given  in  5 -grain  doses  every  two  hours 
for  a  day,  then  every  four  hours  until  the  stools  are  normal  in 
quantity  and  frequency.  It  is  rarely  necessary  to  resort  to  the 
mineral  astringents,  lead  sulphate  or  copper  sulphate.  Should 
it  be  necessary,  either  one  can  be  given  in  5 -grain  doses  three 
times  a  day.  A  starch  enema  will  check  a  profuse  diarrhea. 
In  every  case  the  regulation  of  food  is  of  primary  importance. 

SENILE  CYSTITIS 

Etiology. — This  is  a  form  of  chronic  cystitis  due  to  disten- 
tion of  the  bladder  and  the  presence  of  decomposing  urine 
retained  either  in  the  cystic  pockets  formed  in  the  process  of 
senile  degeneration  of  the  organ  or  in  the  bladder  through  pros- 
tatic obstruction.  When  bacteria  are  introduced  from  without, 
as  by  a  dirty  catheter,  the  disease  begins  as  a  mild  acute  cystitis. 
In  many  cases  of  chronic  cystitis  there  is  a  history  of  gout  but 
the  connection  between  the  two  is  uncertain.  The  old  theory 
that  the  enforced  rest  imposed  by  an  attack  of  acute  gout  causes 
retention  of  urine  with  atony  and  dilatation  of  the  bladder,  the 
retained  urine  producing  a  chronic  cystic  catarrh,  is  hardly 
tenable  as  an  explanation  of  the  relation  between  the  two  dis- 
eases. It  may  explain  the  frequency  of  chronic  cystitis  when- 
ever prolonged  rest  in  bed  is  enforced.  It  is  more  probable 
that  the  increased  amount  of  uric  acid  in  the  urine  is  responsible 
for  the  irritation  of  the  mucous  lining  of  the  bladder.  This, 
however,  does  not  cause  the  senile  form  of  chronic  cystitis  in 
which  there  is  an  absence  of  glairy  mucus  found  in  the  ordinary 
form.  The  ordinary  form  of  chronic  cystitis  may  occur  in  the 
aged  either  as  a  sequel  to  an  acute  cystitis,  or  to  the  irritation 
produced  by  a  stone  or  growth,  or  by  the  urine  the  character  of 
which  had  been  altered  through  retention,  increased  acidity  or 
by  abnormal  constituents. 

Symptoms. — In  senile  cystitis  there  are  the  usual  symptoms 
of  senile  degeneration  the  presence  of  pockets  being  revealed  by  the 
immediate  finding  of  some  more  urine  in  a  bladder  which  had 
been  thoroughly  emptied  by  catheterization;  especially  is  this 


MODIFIED   DISEASES    OF    THE    SKIN  229 

the  case  if  the  patient  changes  his  position  rapidly  from  side  to 
side  and  is  recatheterized.  In  addition  to  these  symptoms  there 
is  a  constant  dull  ache,  increasing  upon  pressure  or  whenever 
the  bladder  is  distended.  This  ache  comes  on  gradually,  is 
never  severe  but  persists  after  the  bladder  is  emptied.  The 
urine  is  generally  turbid,  ammoniacal  and  contains  bacteria.  In 
the  ordinary  chronic  form  there  are  the  same  symptoms  of 
persistent  ache  and  ammoniacal,  rarely  acid,  urine,  but  the 
urine  contains  a  glairy  mucus,  and  sometimes  pus,  and  there  is 
frequently  ulceration  of  the  mucous  membrane  with  more  pro- 
nounced pain  and  painful  pressure  points.  There  is  also  in 
both  forms  a  frequent  desire  to  urinate  though  the  bladder 
contains  but  a  few  drops  of  urine.  The  ordinary  form  gives  a 
history  of  stone,  growth,  or  an  acute  cystitis.  In  rare  cases 
there  is  a  history  of  urethritis,  more  often  one  of  gout  or  chronic 
rheumatism. 

Treatment. — In  the  senile  form  of  cystitis  the  treatment  is 
primarily  that  of  degeneration  or  hypertrophy.  The  bladder 
should  be  frequently  emptied,  care  being  taken  to  thoroughly 
sterilize  the  catheter.  Catheterization  can  be  entrusted  to  the 
patient  with  strict  injunction  as  to  cleanliness.  A  urinary 
antiseptic,  preferably  hexamethylenamine,  should  be  given  in 
5 -grain  doses  three  times  daily  until  the  disappearance  of 
turbidity  shows  that  the  urine  is  free  from  bacteria.  Oil  of 
sandalwood  in  io-minim  doses  three  times  a  day  will  relieve 
the  irritability  of  the  bladder.  Irrigation  is  of  little  service 
in  this  form  of  cystitis  except  as  a  momentary  cleansing  wash. 
A  2  per  cent,  solution  of  boric  acid  or  a  4  per  cent,  solution  of 
sodium  borate  can  be  used,  but  the  stronger  silver  solutions 
are  contraindicated. 

MODIFIED  DISEASES  OF  THE  SKIN 

While  almost  all  affections  of  the  skin  present  peculiarities 
in  the  aged  due  to  the  senile  changes  of  the  skin  a  few  present 
such  pronounced  modifications  that  they  will  be  described  sepa- 
rately. In  this  group  will  also  be  placed  diseases  which  occur 
most  frequently  or  exclusively  in  the  aged  and  which  would 
therefore  belong  to  the  fourth  group  (preferential  diseases). 
Some  of  these  diseases  as  well   as  the   benign  and  malignant 


230  PATHOLOGICAL   OLD   AGE 

growths  are  apparently  perversions  of  the  normal  senile  changes 
in  the  skin.  The  true  senile  diseases  of  the  skin  are  senile 
pruritus,  the  vascular  group,  senile  purpura,  and  senile  gangrene, 
the  benign  growth  group,  senile  angioma,  sebaceous  nevi,  warts, 
keratoma  and  cornua,  the  malignant  growth  group  and  the 
senile  changes  in  the  hair,  nails  and  glands. 

As  it  is  impossible  to  harmonize  the  divergent  views  of  der- 
matologists as  to  the  etiology  or  pathology  of  diseases  giving 
similar  clinical  symptoms,  and  as  the  chaotic  state  of  the  nomen- 
clature still  further  tends  to  confusion,  it  was  deemed  best  to 
adhere  to  the  nomenclature  adopted  by  Jadassohn  whose  work 
in  senile  dermatoses  is  best  known.  His  views  are  generally 
followed  where  they  do  not  conflict  with  the  views  of  the  author. 

(A  frequent  source  of  error  in  dealing  with  senile  affections 
of  the  skin  is  senile  pruritus,  unassociated  with  the  lesion,  but 
which,  occurring  in  the  same  region,  would  make  it  appear  as  a 
pruritic  affection.  The  history  of  a  possible  antecedent  pruritus 
should  be  sought  for  in  every  case  before  deciding  upon  a  diag- 
nosis.) 

SENILE  PURPURA 

Senile  purpura  appears  in  two  forms.  Transitory  senile 
purpura  occurs  as  hemorrhagic  macules  or  papules  on  the  lower 
limbs  of  aged  individuals  in  whom  there  are  local  circulatory 
disturbances  such  as  varicose  veins  or  generally  weak  circula- 
tion. The  spots  appear  after  prolonged  standing  or  walking 
and  disappear  when  the  limbs  are  at  rest  in  a  horizontal  posi- 
tion. It  is  probably  due  to  capillary  engorgement  brought 
about  by  gravitation  and  weakened  return  circulation.  The 
affection  is  insignificant,  producing  no  distress,  and  is  not 
amenable  to  treatment.  Yellowish  discolorations  may  remain 
for  some  length  of  time. 

Permanent  senile  purpura  occurs  most  frequently  on  the 
back  of  the  forearms  and  hands,  especially  in  those  accustomed 
to  work  with  the  forearms  exposed.  It  begins  in  brick  red 
spots  which  increase  in  size  and  become  confluent.  Later  they 
are  surrounded  by  a  reddish  border  while  the  macules  become 
darker  and  assume  the  color  of  blood.  After  a  few  weeks  the 
color  becomes  brown  and  turns  gradually  lighter  until  after 


SENILE   ANGIOMA  23 1 

a  few  months  the  spots  have  disappeared  entirely  or  leave 
but  a  slight  discoloration.  The  eruption  occurs  in  groups  and 
may  reoccur  at  irregular  intervals.  The  disease  is  probably  due 
to  ruptured  degenerate  capillaries  with  transudation  of  blood 
into  the  surrounding  tissue.  It  produces  no  distress,  does  not 
affect  the  health  and  nothing  can  be  done  for  it.  Slight  trauma 
may  produce  serious  hemorrhage  in  these  cases.  Purpura 
facticia  senilis,  described  by  Jadassohn,  is  a  purpura  produced 
on  the  back  of  the  forearm  when  a  rough  object  is  rubbed  over 
it.     It  resembles  the  permanent  form. 

SENILE  ANGIOMA 

Senile  angioma  or  capillary  varix  is  a  frequent  affection  of 
the  aged. 

Etiology. — Its  etiology  is  unknown  but  it  occurs  most  fre- 
quently among  those  much  exposed  to  variations  of  tempera- 
ture without  sufficient  protection.  It  is  more  often  met  with 
in  the  country  than  in  the  city. 

Pathology. — The  angioma  consists  of  a  minute  mass  of  dilated 
capillaries  lying  under  the  epidermis  and  sometimes  imbedded 
in  the  deeper  layers  of  the  derma.  It  thus  forms  a  cavernous 
body  filled  with  blood.  In  rare  cases  the  blood  is  coagulated 
forming  thrombi. 

Symptoms. — The  angioma  appear  as  dark  red,  round  or  oval 
macules  rarely  larger  than  a  pin's  head.  If  much  larger  they 
may  be  felt  as  smooth  elastic  papules.  If  deeply  situated  the 
color  may  be  purplish  or  blue  and  under  glass  pressure  the  color 
becomes  lighter  but  does  not  disappear  entirely.  The  favorite 
location  is  on  the  back  and  chest  but  they  may  appear  in  other 
localities  and  there  is  no  regularity  in  their  distribution.  A 
senile  angioma  on  the  free  border  of  the  lips  is  described  by 
Pasini.  It  occurs  generally  as  a  solitary  lesion  on  the  lower 
lip  near  the  median  line,  the  color  is  dark  red,  and  there  are 
sometimes  fine  branch-like  projections.  The  angioma  produce 
no  distress,  and  the  patient  is  often  unconscious  of  them.  They 
may  persist  for  years  and  do  not  affect  the  health. 

Treatment. — Nothing  need  be  done  for  angioma.  Should 
their  removal  be  desired  for  cosmetic  reasons  electrolysis, 
thermocautery,    galvanocautery     or    other    cauterization    will 


232  PATHOLOGICAL   OLD   AGE 

effect  a  cure.     There  is,  however,  danger  of  producing  more 
serious  skin  lesions. 

SENILE  SEBACEOUS  NEVI 

These  are  white  or  yellowish,  rather  hard  papules,  the  size 
of  the  head  of  a  pin  or  slightly  larger  generally  found  on  the  fore- 
head and  occasionally  on  the  cheeks  and  nose.  They  are  some- 
times covered  by  fine  telangiectases.  They  usually  contain 
two  or  three  enlarged  pores,  often  topped  by  comedones,  from 
which  sebum  can  be  expressed.  It  is  a  question  whether  they 
are  nevi  or  simply  hypertrophied  sebaceous  glands.  They  are 
insignificant  lesions,  producing  no  distress  nor  interfering  with 
health.  They  are  important,  however,  from  a  diagnostic  point 
as  they  may  be  mistaken  for  soft  nevi,  molluscum  contagiosum, 
milium,  warts  or  beginning  epithelioma.  The  diagnosis  is  based 
upon  the  expression  of  sebum  and  the  ability  to  compress  the 
papule  afterward. 

No  treatment  is  required  except  on  cosmetic  grounds.  A 
simple  method  is  to  squeeze  out  the  sebum,  wash  the  spots  with 
alcohol,  then  apply  a  solution  of  tannic  acid.  If  this  fails,  ex- 
cision or  electrolysis  must  be  resorted  to. 

SENILE  KERATOMA 

Senile  keratoma,  called  also  precancerous  senile  keratosis, 
senile  dandruff,  concrete  sebaceous  acne,  etc.,  is  a  warty  growth 
occurring  generally  upon  the  face  and  dorsum  of  the  hands, 
rarely  upon  the  neck  or  scalp.  Its  etiology  is  unknown.  It 
consists  of  a  hyperplasia  of  epithelial  tissue,  the  corneal  layer 
is  thickened,  the  prolongations  of  the  rete  extending  further 
into  the  corium. 

Symptoms. — Senile  keratomas  begin  either  as  a  small  yellow- 
ish, reddish,  or  brownish,  dry  plaque,  or  as  a  slightly  elevated 
papillomatous  wart.  The  plaques  gradually  and  slowly  increase 
in  height  and  sometimes  in  size,  ranging  from  the  head  of  a  pin 
to  a  bean  or  larger ;  they  are  granular  or  rough  to  the  touch  and 
are  covered  by  fine  dry  or  fatty  scales.  The  upper  layers  of  the 
scales  are  easily  removed  but  the  lower  layer  is  closely  adherent 
and  if  removed  leaves  a  bleeding  surface,  granular  and  but 
slightly  elevated,  or  even  depressed  below  the  level  of  the  skin. 
In  advanced  cases  the  keratoma  occasionally  appear  as  masses 


SENILE   WARTS  233 

of  large  crusts  covered  by  scales.  They  may  remain  unaltered 
for  years;  sometimes,  however,  one  may  spread,  the  tissue 
becomes  indurated,  ulcerates,  bleeds  readily,  and  assumes  the 
character  of  an  epithelioma. 

It  is  often  impossible  to  determine  whether  the  growth  is  a 
senile  wart  or  a  precancerous  keratosis,  yet  this  is  of  great  prog- 
nostic importance.  It  is  safe  to  say  that  the  wart  never  be- 
comes malignant  except  after  traumatism,  prolonged  irritation 
or  some  such  cause  as  is  usually  recognized  as  an  exciting  factor 
in  the  causation  of  epithelioma.  The  senile  keratoma  may  be- 
come malignant  without  any  known  cause.  Owing  to  the  ex- 
treme rarity  of  epithelioma  following  warts,  this  prognosis  can 
be  virtually  disregarded,  while  in  keratoma  it  must  be  kept  in 
mind.  The  differential  diagnosis  is  therefore  of  importance  not 
alone  on  account  of  the  prognosis  but  also  on  account  of  the  treat- 
ment, warts  requiring  virtually  none,  while  keratoma  on  account 
of  the  possibility  of  its  transformation  into  a  malignant  growth 
should  be  treated  as  soon  as  recognized.  Diagnostic  points  are 
the  location,  the  origin,  and  the  presence  or  absence  of  scales. 

Treatment. — Keratomas  should  be  removed.  This  can 
sometimes  be  accomplished  by  inunction  with  a  50  per  cent, 
resorcin  ointment,  but  its  action  is  slow.  More  rapid  and  more 
effective  is  radiotherapy,  the  usual  method  of  treatment  to-day. 
If  the  growth  becomes  malignant  total  extirpation  by  the  knife 
is  necessary. 

Cornua  Cutanea. — Cutaneous  horns  are  growths  which  on 
account  of  their  prominence  have  been  called  horns.  They 
may  be  of  the  nature  of  warts  or  keratoma,  but  start  most 
frequently  from  a  plaque  of  the  latter.  The  surface,  consisting 
of  the  horny  layer  of  epithelium,  is  hard,  the  interior  is  soft, 
either  fatty,  or  friable  fasciculi  composed  of  cells  of  the  rete. 
The  cornua  filiforme  is  a  thin  warty  growth  sometimes  found  on 
the  eyelids.  It  is  from  5  to  10  mm.  in  length,  1  to  2  mm.  in 
diameter,  and  is  of  no  importance.  The  ordinary  form  is  to  be 
treated  as  a  keratoma. 

SENILE  WARTS 

Senile  warts  are  among  the  most  frequent  dermal  affections 
of  old  age,  occurring  mostly  after  the  fiftieth  year  and  increasing 


234  PATHOLOGICAL   OLD   AGE 

in  number  with  advancing  age.  Their  etiology  is  unknown  but 
it  is  supposed  to  be  due  to  some  perversion  in  the  normal 
senile  degeneration  of  the  rete  mucosum.  There  is  a  hyper- 
plasia of  the  rete,  the  prolongations  projecting  downward  into 
the  corium,  the  papillae  extending  upward  into  the  excrescence 
produced  by  the  rete  and  its  epithelial  covering. 

Symptoms. — Senile  warts  are  soft,  flat,  pigmented  and  usu- 
ally of  a  granular  appearance.  They  generally  range  in  size 
from  a  pin's  head  to  a  bean,  but  occasionally  they  are  much 
larger.  They  are  round  or  irregular  in  shape  and  usually  ex- 
tend but  little  above  the  surface  of  the  skin.  The  apex  may  be 
smooth  or  finely  granular,  occasionally  coarsely  granular  or  rough 
and  the  whole  growth  may  be  closely  adherent  to  the  skin,  like 
a  plaque,  or  attached  by  a  broad  neck,  rarely  by  a  thin  pedicle. 
The  wart  can  be  removed  by  a  sharp  spoon  or  by  the  finger  nail, 
leaving  a  granular  bleeding  surface  which  is  soon  repaired.  The 
favorite  location  for  senile  warts  is  the  back,  but  they  may  occur 
upon  the  chest,  neck,  abdomen,  occasionally  on  the  face,  scalp,  or 
extremities.  Occurring  on  the  face  or  on  the  dorsal  surface  of 
the  hands,  they  may  be  senile  keratoma  instead.  (See  Senile 
Keratoma.) 

Treatment. — The  senile  warts  sometimes  disappear  without 
treatment.  If  their  removal  is  desired,  any  of  the  ordinary 
mechanical  or  medicinal  caustics  can  be  employed,  care  being 
taken  not  to  injure  the  surrounding  skin. 

ROSACEA 

The  rosacea  of  Jadassohn  is  the  disease  usually  described  as 
acne  rosacea,  not  the  simple  rosacea  in  which  there  is  telan- 
giectasis without  seborrhea.  Rosacea  is  a  senile  disease  since 
it  rarely  occurs  before  the  forty -fifth  year. 

Etiology. — The  cause  is  unknown.  It  occurs  most  fre- 
quently in  those  who  use  alcohol  to  excess  and  it  is  often  found  in 
those  suffering  from  digestive  disorders.  It  also  occurs  occa- 
sionally in  women  during  or  after  the  climacteric. 

Pathology. — Rosacea  is  a  hyperplasia  of  the  sebaceous  glands 
with  retention  of  sebum,  and  dilatation  and  anastomosis  of  the 
surrounding  capillaries.  An  inflammatory  or  pustular  acne 
eruption  and  comedones  appear  frequently  as  a  complication. 


ROSACEA  235 

Symptoms. — Rosacea  appears  most  frequently  about  the 
nose,  occasionally  on  the  cheeks,  chin  or  lips,  rarely  elsewhere. 
It  begins  with  a  pinkish  erythema  gradually  getting  darker  and 
later  minute  blood-vessels  are  seen  ramifying  over  the  surface. 
The  surface  feels  greasy  and  the  dilated  openings  of  the  seba- 
ceous glands  are  capped  by  particles  of  dust.  A  minute  mass  or 
string  of  sebum  can  be  expressed.  In  the  second  stage  of  the 
disease  papules  or  nodules  arise  from  the  erythematous  surface. 
These  range  from  a  pinhead  to  a  pea  in  size,  are  firm,  dark, 
painless  and  present  minute  tortuous  blood-vessels.  In  some 
cases  the  nodules  grow  to  the  size  of  a  walnut,  in  rare  cases  they 
become  still  larger  forming  rhinophyma  tumors.  These  may 
be  single  or  multiple,  round,  lobulated  or  pendulous  masses, 
dark  red  in  color,  painless,  but  producing  a  conspicuous  deform- 
ity. According  to  Kaposi  the  rosacea  nose  of  the  wine  drinker 
is  bright  red,  of  the  beer  drinker  cyanotic  or  violet,  of  the  liquor 
drinker  it  is  dark  blue. 

Treatment. — The  underlying  cause  must  first  be  removed  if 
possible.  Of  special  importance  in  internal  medication  is  the 
cure  of  gastric  and  intestinal  disorders.  The  local  treatment 
must  meet  two  indications,  the  cure  of  telangiectasis  and  of 
the  glandular  hyperplasia.  The  former  condition  can  be  some- 
times relieved  by  hypodermic  injection  of  a  tenth  (1/10)  per. 
cent,  solution  of  adrenalin,  or  by  the  local  inunction  of  an  oint- 
ment of  the  same  strength.  If  this  fails,  either  the  negative 
galvanic  current  may  be  used  as  in  the  treatment  of  hyper- 
trichosis, or  a  fine  thermocautery,  or  the  knife  slitting  the  vessels. 
Operative  work  about  the  face  of  the  aged  is  often  followed  by 
worse  disfigurement  and  sometimes  by  ulcers  and  cicatrices 
which  may  develop  malignancy.  Gottheil  recommends  in  the 
early  stage  of  the  disease  a  mild  sulphur  lotion  and  internally 
ichthyol  in  1-  or  2 -grain  doses  after  meals.  Zeller  recommends 
that  the  lesion  be  painted  with  the  tincture  of  the  chloride  of 
iron  twice  daily  for  five  days  or  until  a  thick  crust  is  formed  and 
considerable  inflammation  results.  Sulphur  ointment  is  then 
applied  until  the  inflammation  disappears  when  the  painting 
with  iron  is  to  be  repeated.  Zeissel  claims  to  have  cured  cases 
by  this  procedure.  An  effective  means  for  diminishing  the 
glandular  enlargement  is  by  the  use  of  tannic  acid.  The  surface 
is  first  thoroughly  washed  with  alcohol,  then  pencilled  over  with 


236  PATHOLOGICAL   OLD   AGE 

a  solution  of  tannic  acid.  Resorcin  is  sometimes  effective. 
For  the  tumor  growth  radiotherapy  has  given  the  most  satis- 
factory results. 

DERMATOSES  WITH  MINOR  MODIFICATIONS  IN  OLD 

AGE 

Eczema 

The  various  chronic  eczemas  are  of  frequent  occurrence ;  the 
acute  form  appears  seldom,  and  then  mostly  about  the  genitals 
and  lower  limbs  after  scratching.  The  disease  is  more  tenaceous 
in  the  aged,  the  itching  is  more  severe,  the  scale  and  crust 
formations  are  more  profuse.  The  acute  hyperemia,  diffuse 
edema  and  serous  exudation  are  less  pronounced  but  there  is 
frequently  a  sero-sanguineous  or  purulent  sanguineous  discharge 
with  intense  pruritus.  In  many  cases  the  eczema  follows  scratch 
lesions  and  eczema  intertrigo  is  frequently  met  with  in  the  aged. 
The  eczema  following  scratches  appears  usually  as  linear  hemor- 
rhagic lesions  which  may  leave  small  ulcers  or  if  situated  over 
veins  they  may  cause  phlebitis  or  thrombosis.  After  the  crusts 
disappear  their  site  is  marked  by  grayish  or  brownish  lines. 
The  diagnosis  of  eczema  in  the  aged  is  simple.  The  most  fre- 
quent type,  eczema  rubrum,  presents  the  typical  symptoms, 
redness,  swelling,  infiltration,  exudation  and  crusting  with  pruri- 
tus. When  occurring  as  a  linear  lesion  following  scratching  it 
might  be  mistaken  for  herpes,  but  the  latter  disease  occurs  only 
as  large  vesicles  following  a  nerve  trunk  or  the  area  of  its  distribu- 
tion, it  is  painful,  and  the  pain  is  persistent  remaining  sometimes 
for  months  after  the  vesicles  disappear.  If  itching  is  present 
we  must  determine  whether  it  is  a  senile  pruritus  or  due  to  this 
disease.  (Zoster  senilis  is  a  far  more  serious  disease  and  will 
be  considered  separately.)  Impetigo  contagiosa  may  simulate 
eczema  but  is  rare  in  the  aged,  it  occurs  as  discrete  vesicles  and 
the  crusts  appear  as  if  stuck  upon  the  skin.  The  vesicular 
type  of  eczema  may  be  mistaken  for  erysipelas,  dermatitis 
venenata  or  syphilis,  but  the  history  will  generally  suffice  to 
clear  up  the  diagnosis. 

Acne  has  no  itching,  the  infiltration  is  usually  limited  to  the 
sebaceous  glands  and  comedones  are  found  among  the  pustules. 

Dermatitis  is  generally  of  traumatic  origin,  occurs  suddenly 


ECZEMA  237 

and  subsides  upon  removal  of  the  cause.  Simple  erythema,  due 
to  hypermia,  has  no  exudation.  Where  exudation  does  occur  it 
is  always  an  eczema.  In  herpes  febrilis  the  vesicles  are  grouped 
about  mucous  outlets  and  occur  during  febrile  affections. 
Lichen  rubrum  is  rare  in  the  aged  and  it  can  be  readily  differ- 
entiated from  eczema  by  the  dilated  orifices  of  hair  follicles 
when  the  scales  covering  the  papules  are  removed.  Psoriasis, 
also  rare  in  the  aged,  may  be  mistaken  for  papular  eczema  after 
scale  formation  takes  place,  but  the  defined  contour,  abundance 
of  shiny  scales,  absence  of  moisture  and  single  type  of  lesion 
should  clear  up  the  diagnosis.  The  presence  of  senile  pruritus 
sometimes  makes  the  diagnosis  difficult.  This  must  be  ex- 
cluded. 

Treatment. — In  the  treatment  of  eczema  and  in  almost  all 
dermatoses  of  old  age,  we  find  some  difficulties  that  are  not 
present  in  earlier  life.  The  skin  being  dryer  and  surface  circu- 
lation poorer,  drugs  are  not  absorbed  as  readily,  they  are  not 
as  active,  the  healing  process  is  slower  and  irritants  are  liable 
to  produce  necrosis  and  gangrene.  The  epidermis  being  thinner 
and  dryer  is  readily  rubbed  off,  leaving  an  excoriated  surface 
which  becomes  a  good  field  for  pathogenic  germ  propagation, 
hence  the  frequency  of  purulent  and  erysipelatous  infection. 
The  uncertainty  of  the  underlying  cause  in  most  dermatoses 
necessitates  generally  a  purely  empirical  method  of  procedure. 
In  some  cases  regulation  of  the  diet  will  effect  a  cure,  in 
others  protection  from  exposure  to  dust  or  water  will  suffice, 
in  still  others  internal  medication  is  required;  sometimes  a 
dermatosis  will  disappear  without  treatment,  in  other  cases 
nothing  apparently  helps.  In  the  treatment  of  eczema  the 
cause  should  be  determined  if  possible  and  eliminated.  This 
can  usually  be  done  if  there  is  a  local  cause,  as  scratching, 
intertrigo,  vocational  irritation  or  a  parasite.  If  no  cause  can 
be  discovered  attention  must  be  paid  to  the  ordinary  dietetic 
and  hygienic  rules  and  we  must  depend  upon  the  local  medi- 
cation. Water  should  be  excluded  except  in  the  inflammatory 
stage  when  clothes  dampened  with  a  weak  solution  of  lead  or 
aluminum  acetate  can  be  used.  After  the  inflammatory  stage 
has  passed  an  alcoholic  solution  of  1/4  per  cent,  of  thymol 
should  be  applied  for  an  hour  several  times  daily  while  in  the 
intervals,   the  surface   should  be  covered  with  zinc  stearate. 


238  PATHOLOGICAL   OLD   AGE 

Other  drugs  that  are  of  service  in  some  cases  are  zinc,  lead 
and  bismuth  salts,  white  precipitate,  ichthyol,  tar,  pyrogallol, 
salicylic  acid,  sulphur,  etc.,  in  powder  or  ointment.  Radio- 
therapy, massage,  and  other  mechanical  measures  have  been 
tried  with  occasional  succes. 

Pityriasis  tabescentium,  in  which  fine  scales  of  dried  epithe- 
lium can  be  rubbed  or  scratched  off  the  skin,  is  a  normal  senile 
condition,  not  a  disease.  Other  forms  of  pityriasis  are  ex- 
tremely rare  in  the  aged.  Prurigo  senilis  is  described  by  Pic  as 
"La  maladie  cutanee  la  plus  commune  chez  de  Viellard  est  le 
prurigo."  On  the  other  hand  Jadassohn  declares  that  the  true 
prurigo,  prurigo  Hebrae,  does  not  occur  in  the  aged  and  is  further- 
more a  rare  disease  at  any  period  of  life. 

Psoriasis  when  occurring  in  the  aged  is  usually  carried  over 
from  earlier  life  and  does  not  differ  essentially  from  the  earlier 
disease.  The  scaly  formation  may  be  less  profuse  and  the  lesions 
may  be  lighter  in  color  and  occasionally  there  is  itching,  prob- 
ably a  local  senile  pruritus.  In  the  treatment,  which  is  purely 
empirical,  irritating  drugs  must  be  avoided. 

Dermatoses  due  to  mechanical,  chemical  or  thermic  causes 
occur  in  the  aged  less  frequently  than  in  earlier  life,  the  aged 
being  less  exposed  to  them.  Corns,  bunions,  hammer  toes  and 
other  pedal  defects  are  frequently  found  and  present  no  difficulty 
in  their  diagnosis.  Bedsores  occur  frequently  and  may  become 
gangrenous.     The  diagnosis  is  simple. 

Burns  are  far  more  serious  in  the  aged  on  account  of  their 
constitutional  effect  and  the  slow  local  regeneration.  Atten- 
tion must  be  paid  to  the  heart  and  kidneys  apart  from  the  local 
indication. 

Pernio  is  rare.  Dubreuil  described  a  form  of  chronic  senile 
pernio  occurring  in  the  aged,  not  accompanied  by  bullae  or  ulcers 
but  by  circulatory  disturbances  which  become  pronounced  with 
the  advent  of  cold  weather  and  gradually  disappear  in  the 
spring.  The  parts  affected  become  tumefied,  irregulaily  marked 
with  dark  red  or  violet  marbling,  and  are  numb.  During  the 
height  of  the  symptoms  the  parts  are  intensely  painful,  swollen 
and  dark.     This  condition  is,  however,  rare. 

Vocational  dermatoses  are  infrequent  and  present  no  marked 
difference  from  such  conditions  in  maturity.  Toxic  dermatoses 
probably  constitute  the  majority  of  senile  dermic  affections 


BACTERIAL   DERMATOSES  239 

but  the  etiology  of  many  is  still  disputed.  It  appears  certain 
that  the  same  toxic  cause  may  produce  various  lesions  and  dis- 
eases and  the  same  disease  may  be  due  to  a  variety  of  causes, 
toxic  or  non-toxic.  It  is  consequently  impossible  to  make  a 
definite  classification  of  toxic  dermatoses  except  where  the 
etiology  is  positively  known,  such  as  urticaria  and  erythema 
multiforme,  dermatitis  herpetiformes,  pemphigus,  etc.  Parasitic 
dermatoses  are  infrequent  in  the  aged,  perhaps  because  they  are 
less  exposed,  or  less  hairy,  or  because  the  senile  skin  is  a  poor 
field  for  their  propogation.  When  they  do  appear  they  do  not 
differ  from  the  diseases  of  maturity.  Pediculi  vestimentorum 
occur  occasionally  among  the  same  class  as  in  maturity,  but  do 
not  present  any  difference.  Parasitic  disease  may  be  mistaken 
for  senile  pruritus,  and  the  scratching  may  result  in  eczema. 
Mycoses  are  rare  in  the  aged  and  do  not  differ  from  the  mycoses 
of  maturity.  A  body  favus  is  occasionally  seen  shortly  before 
death  where  there  had  been  a  prolonged  cachexia,  as  carcinoma, 
tuberculosis,  etc.  Jadassohn  believes  it  is  due  to  an  abnormally 
located  mycelium  growth. 

Bacterial  dermatoses  occur  rather  frequently.  (The  most 
important  of  these,  erysipelas,  will  be  treated  among  the  infec- 
tious diseases  of  the  fifth  group.)  The  pyodermatoses  are  seen 
occasionally  either  as  primary  affections  or  secondary  to  other 
diseases,  the  latter  sometimes  predominating  over  the  original 
disease.  The  streptogenic  dermatoses  appear  in  two  forms, 
impetigo  contagiosa  and  ecthyma.  The  true  impetigo  conta- 
giosa does  not  occur  in  the  aged  but  a  mild  vesicular  eruption 
of  streptogenic  origin  is  occasionally  found  as  a  complication  of 
other  dermatoses.  These  present  superficial  vesicles  which 
rupture,  forming  transparent  yellowish  crusts,  and  produce  no 
constitutional  effect.  Ecthyma  occurs  occasionally  as  a  second- 
ary disease  in  pruritic  affections.  It  is  probable  that  the  mild 
impetigo  is  the  outcome  of  a  non-virulent  strain  of  streptococci, 
while  ecthyma  is  the  result  of  a  virulent  strain  of  these  germs. 
The  latter  may  begin  as  a  vesicular  eruption,  soon  becoming 
pustular,  or  it  may  begin  with  pustules  which,  after  rupture  and 
drying,  produce  opaque  yellow  scabs.  They  are  more  deep 
seated  than  the  other  and  may  cause  ulcers.  Local  antiseptics 
are  indicated.  The  staphylo genie  dermatoses  generally  attack 
the  glandular  orifices  and  tubes,  producing  inflammation  and 


240  PATHOLOGICAL   OLD   AGE 

abscess.  The  sudoriparous  glands  are  apparently  immune 
from  attack  in  the  aged,  but  the  sebaceous  glands  and  hair 
follicles  are  occasionally  the  seat  of  inflammation  from  this 
source.  More  serious  affections  due  to  staphylococcic  infec- 
tion are  boils  and  carbuncles.  The  simple  folliculitis  super- 
ficialis  consists  of  numerous  small  pustules  upon  an  inflamed 
base.  It  follows  local  irritation  with  infection,  gives  little 
distress  and  may  persist  for  weeks  or  months  if  not  treated. 

Furuncles  may  follow  a  folliculitis  as  an  extension  of  the 
pyogenic  process,  or  it  may  begin  as  a  more  intense  and  exten- 
sive folliculitis  or  a  perifolliculitis.  In  this  as  in  all  pyogenic 
affections  of  the  skin  there  must  be  a  peculiar  state  of  the  system 
to  furnish  a  suitable  field  for  the  existence  and  development  of 
the  germs.  This  is  found  in  diabetes,  nephritis,  gastric  or 
intestinal  disorders  causing  autointoxication,  circulatory  dis- 
eases, etc.  Diabetes  especially  favors  the  production  of  fur- 
uncles and  carbuncles. 

Carbuncles  are  virtually  deep-seated  furuncles  of  large  size  in 
which  the  integument  is  undermined  and  several  sacs  are  formed. 
These  sacs  hold  pus  which  makes  its  way  to  the  surface  through 
one  or  several  openings.  There  are  usually  grave  constitutional 
symptoms  present.  In  simple  folliculitis  antiseptic  lotions  or 
ointments  and  the  observance  of  dietetic  and  hygienic  rules 
generally  effect  a  cure.  If  crusts  have  formed  these  must  be 
removed.  In  furunculosis  the  treatment  of  the  cause  is  of 
primary  importance.  If  it  is  a  chronic  disease  like  diabetes  or 
nephritis  there  may  be  successive  crops  which  must  be  dealt 
with.  Occasionally  internal  medication  with  arsenic  is  of 
service.  Serum  (vaccine)  therapy  has  given  brilliant  results 
when  used  at  the  onset  of  the  disease  but  after  the  boil  has 
developed  it  is  useless,  as  the  slough  must  be  removed  before 
healing  can  be  effected.  A  furunculosis  vaccine  is  on  the 
market  with  reports  of  remarkable  results  in  furuncles  and 
boils.  Furuncles  can  sometimes  be  aborted  if  the  cause  can  be 
rapidly  eliminated.  If  due  to  autointoxication  following  con- 
stipation, active  catharsis  is  sometimes  effective  and  this  is  the 
rationale  of  magnesium  sulphate  treatment,  which  is  occasion- 
ally curative.  If  this  fails,  excision  or  the  cautery  becomes 
necessary.  Carbuncles  must  be  treated  like  boils,  but  if  the 
vaccine  therapy  fails,  other  abortive  measures  are  futile.     The 


TUBERCULAR  DERMATOSES  24 1 

cautery  or  the  knife  should  be  used  early  to  allow  free  discharge 
of  the  pus  and  the  slough  should  be  picked  out  with  a  forceps. 
The  injection  of  carbolic  acid  is  intensely  painful  and  may  pro- 
duce extensive  necrosis.  The  constitutional  symptoms  of 
septic  infection  as  well  as  the  causative  condition  must  not  be 
neglected. 

Tubercular  dermatoses  occur  seldom  in  the  aged  and  then 
generally  as  some  form  of  lupus.  The  senile  lupus  does  not 
differ  from  the  lupus  of  earlier  life.  Beginning  as  a  well-defined 
slightly  elevated  patch,  light  brown  in  color,  and  about  the  size 
of  a  hemp  seed,  or  slightly  larger,  it  increases  very  slowly  in 
size,  while  the  center  becomes  depressed.  The  top  is  covered 
with  glistening  epithelial  scales.  It  may  remain  small  through- 
out life,  or  it  may  increase  to  the  size  of  several  inches  in  di- 
ameter, it  may  remain  indolent  for  years  or  it  may  expand  more 
rapidly,  invading  the  deeper  tissues  and  becoming  nodular  and 
ulcerous  at  the  top,  or  it  may  develop  into  an  epithelioma.  In 
cases  originating  in  old  age  the  lesion  is  often  formed  rapidly 
while  the  further  progress  is  slow. 

Earlier  lupus  erythematodes  may  suddenly  become  active 
and  progress  to  suppuration  or  to  tissue  destruction.  In 
some  cases  favorable  involution  and  scar  formation  ensues. 
The  favorite  location  of  lupus  is  the  face ;  occasionally  it  appears 
upon  the  scalp,  rarely  upon  the  hands,  feet,  or  other  portions  of 
the  body.  The  forms  met  with  in  the  aged  are  the  lupus 
erythematodes,  lupus  vulgaris,  and  lupus  vulgaris  erytkematoides 
(Lenoir),  an  intermediate  form.  The  scrofuloderma  are  rare 
in  the  aged  and  are  almost  always  associated  with  glandular 
or  bone  tuberculosis.  Jadassohn  describes  a  tuberculosis  fungosa 
serpiginosa  which  appears  to  partake  of  the  character  of  both 
lupus  and  the  scrofuloderm.  This  occurs  most  frequently  in 
the  lower  extremities  in  connection  with  bone  or  gland  tubercu- 
losis. In  many  cases  there  are  fistulous  openings  from  the  under- 
lying lesions  and  near  their  openings  serpiginous  plaques  form. 
;  These  are  soft,  dark  red,  irregular  patches,  which  grow  rapidly 
and  spread,  while  their  centers  form  scars.  Yellow  miliary  macules 
as  a  result  of  colloid  degeneration  are  sometimes  found  in  the 
scar  tissue.  The  tuberculides  may  be  mistaken  for  syphilides  or 
malignant  growths.  Where  the  diagnosis  rests  between  tuber- 
culosis and  syphilis  if  the  history  is  insufficient,  it  may  be  neces- 
16 


242  PATHOLOGICAL   OLD   AGE 

sary  to  resort  to  the  tuberculin  and  Wasserman  tests  in  order  to 
obtain  the  etiological  factor.  The  history,  and  the  slow  prog- 
ress of  the  tuberculides  will  distinguish  them  from  malignant 
growths.  The  treatment  includes  the  constitutional  treatment 
for  tuberculosis  and  local  treatment  of  the  lesion.  The  Finsten 
light,  radiotherapy  and  the  cautery  are  the  most  effective 
methods  of  treating  the  local  condition.  The  older  methods 
by  inunctions  are  seldom  used,  since  the  mechanical  measures 
are  so  much  more  effective.  Where  a  tuberculous  affection  is 
due  to  an  underlying  lesion,  such  as  a  bone  or  gland  tuberculosis, 
the  latter  must  be  cured  before  the  dermal  lesion  can  be 
improved. 

Lepra  may  occur  in  the  aged  but  it  does  not  differ  from  the 
same  disease  in  earlier  life. 

Angioneuroses  are  sometimes  observed  in  the  aged  but  they 
do  not  differ  from  the  diseases  of  earlier  life  excepting  one 
form  of  herpes  called  zoster  senilis.  In  this  the  symptoms  are 
much  more  severe  and  prolonged  than  in  the  ordinary  herpes 
zoster,  the  disease  is  more  deeply  seated,  the  vesicles  are  in- 
creased in  number  and  size  and  they  frequently  become  trans- 
formed into  pustular  or  hemorrhagic  lesions.  In  some  pustular 
cases  the  pustules  ulcerate,  in  others  they  form  crusts  which 
leave  persistent  cicatrices.  The  hemorrhagic  form  disappears 
leaving  a  deep  pigmentation  or  a  scar.  The  pain  is  intense 
and  may  persist  for  months  after  the  lesion  has  disappeared. 
Secondary  cutaneous  diseases  sometimes  follow. 

In  the  treatment  of  zoster  senilis  the  relief  of  pain  is  the 
first  indication.  Cocaine  in  2  per  cent,  solution  or  ointment  is  • 
the  most  effective  local  measure,  but  the  relief  is  only  temporary. 
Orthoform,  ointments,  antipyrin  injections,  heat,  cold,  have  all 
been  tried  and  occasionally  give  relief;  frequently  they  have 
no  effect.  The  internal  treatment  is  equally  unsatisfactory. 
The  usual  antineuralgic  measures  help  in  some  cases  and  ag- 
gravate the  condition  in  others.  In  many  cases  morphine  be- 
comes necessary.  In  this  as  in  other  neuroses  of  uncertain 
origin  drugs  and  other  therapeutic  measures  must  be  used 
empirically,  employing  each  long  enough  to  observe  an  effect, 
either  physiological  01  therapeu  tic.  If  beneficial  we  will  naturally 
follow  up  that  treatment,  but  if  detrimental  we  must  go  to  the 
opposite  class  of  drugs  or  other  measures. 


DERMAL    GLANDULAR   DISTURBANCES  243 

It  is  sometimes  possible  to  determine  the  etiological  factor; 
in  such  cases  the  elimination  of  that  factor  is  of  first  importance. 
Other  forms  of  herpes  as  well  as  urticaria  and  simple  erythema 
do  not  differ  from  the  same  diseases  in  earlier  life.  They  occur 
in  old  age  under  the  same  conditions  and  require  the  same  treat- 
ment. The  progressive  nutritional  disturbances  are  infrequent. 
Most  of  the  hyperkeratoses  have  a  congenital  basis  and,  while 
diseases  of  earlier  life,  they  may  persist  until  old  age.  They 
generally  disappear  as  a  result  of  the  senile  changes  of  the  skin. 
Hyperpigmentation  and  hypertrichosis  occur  as  a  primary  con- 
dition but  they  present  no  difficulty  in  their  diagnosis  and  are 
of  no  importance  except  possibly  from  a  cosmetic  standpoint. 
Scleroderma  is  rarely  seen  in  the  aged. 

The  retrogressive  pathological  changes  in  the  skin  are 
mostly  variations  of  the  normal  senile  atrophy.  Some,  like 
diffuse  idiopathic  atrophy,  acrodermatitis  atrophicans,  xeroderma, 
etc.,  are  extremely  rare;  others  like  cutis  laxa,  strice,  vitiligo, 
etc.,  are  unimportant  and  require  no  treatment,  while  alopecia 
and  canites  have  been  discussed. 

The  epidermolyses,  the  pemphigus  group,  dermatitis  herpeti- 
formis, and  epidermolysis  bullosa  heredita  are  infrequent  at  any 
time  of  life  and  rare  in  old  age.  When  they  do  occur  they  do 
not  differ  from  those  of  earlier  life. 

Dermal  glandular  disturbances  occur  frequently.  The  sudori- 
parous glands  are  subject  to  hyperidrosis,  anidrosis  and  bromid- 
rosis  (which  have  been  discussed),  miliaria  and  hidrocystoma. 
The  latter  are  retention  cysts,  bluish  and  about  the  size  of  a 
pin  head,  forming  in  the  epidermal  opening  of  the  sweat  glands. 
They  occur  most  frequently  on  the  face  of  elderly  women  who 
work  in  hot  rooms.  When  they  perspire  the  perspiration  fills 
these  minute  cysts  which  then  become  elevated  above  the  sur- 
face of  the  skin.  Upon  rest  in  a  cool  place  they  disappear. 
Miliaria  appears  in  the  aged  as  a  simple  vesicular  affection  of 
little  importance.  It  is  identical  with  the  prickly  heat  of  chil- 
dren. Diseases  of  the  sebaceous  glands  with  the  exception  of 
rosacea  are  comparatively  infrequent.  Seborrhea  oleosa  and 
sicca  occur  almost  exclusively  in  the  form  of  rosacea.  Come- 
dones and  acne  are  rare,  although  an  acne  eruption  does  occa- 
sionally occur  in  women  about  the  time  of  the  climacteric. 
An  artificial  acne  may  be  produced  by  the  staphylococcic  inf  ec- 


244  PATHOLOGICAL   OLD   AGE 

tion  of  a  folliculitis  induced  by  irritating  substances  such  as 
depilatories,  face  washes,  tar  ointment,  etc.  It  disappears  if 
the  cause  is  removed.  The  acne  sderotisans  nucha,  a  follicu- 
litis sometimes  becoming  pustular,  is  occasionally  seen  about 
the  neck  as  a  chronic  condition  carried  over  from  maturity 
The  pustules  may  be  opened  but  there  is  no  certain  method  of 
curing  this  condition.  It  sometimes  gradually  disappears. 
The  sycosis  non-par asitoria  is  probably  the  same  condition  oc- 
curring in  the  beard.  Other  forms  of  acne  occur  occasion- 
ally, but  they  do  not  differ  materially  from  the  diseases  of 
maturity. 

CHRONIC  ULCER 

Chronic  ulcers,  especially  upon  the  legs,  are  frequently  met 
with  in  the  aged.  They  are  generally  due  to  some  slight  trau- 
matism, a  blow,  bruise,  or  scratch,  which  on  account  of  the  poor 
surface  circulation  does  not  heal  readily.  A  chronic  ulcer  may 
also  be  due  to  a  ruptured  varicose  vein.  An  ulcer  occurring 
upon  a  previously  healthy  skin  or  upon  a  keratoma  or  other 
growth  is  generally  malignant  in  spite  of  its  chronic  course. 
It  is  important  before  instituting  treatment  to  determine 
whether  the  lesion  is  a  simple  ulcer,  a  malignant  ulcer  or  a 
syphilitic  or  tubercular  lesion.  These  all  may  look  alike,  run 
a  chronic  course,  gradually  enlarging  and  producing  no  distress 
until  a  sensory  nerve  is  involved.  The  simple  chronic  ulcer 
begins  within  a  few  days  after  the  initial  lesion,  whether  bruise, 
scratch  or  rupture  of  a  vein.  The  traumatic  lesion  does  not  heal, 
a  crust  may  form  while  the  ulcer  below  it  persists.  If  there  is  a 
bruise,  an  abscess  may  form  which  will  open  and  leave  an 
ulcerated  base.  There  is  usually  a  serous  exudation,  or  if 
infected  the  exudation  becomes  seropurulent  or  purulent,  rarely 
serosanguineous.  The  ulcer  grows  in  extent,  becomes  slightly 
deeper,  and  has  sharply  defined  but  not  indurated  or  everted 
edges.  It  is  painless  unless  a  sensory  nerve  is  involved  but 
there  is  often  itching  around  the  margin.  The  syphilitic  ulcer 
can  generally  be  eliminated  by  the  history  of  infection,  the 
primary  lesion  and  the  presence  of  other  lesions.  The  tuber- 
cular form  may  give  a  tubercular  history,  it  originates  in  a 
tubercle  which  breaks  down,  its  advent  is  slow  and  when  ulcer- 


CHRONIC   ULCER  245 

ating  there  is  little  or  no  pus,  thus  differing  from  the  ulcer 
following  a  bruise.  The  malignant  ulcer  has  usually  a  history 
of  a  preceding  growth  or  of  scar  tissue.  The  simple  chronic 
ulcer  does  not  produce  constitutional  symptoms  unless  it  be- 
comes infected,  and  giving  no  local  distress  it  is  often  neglected, 
perhaps  for  years.  If  infected,  the  constitutional  symptoms 
may  become  grave,  while  the  excessive  amount  of  pus  may 
cause  exhaustion.  In  the  treatment  of  these  cases  care  must  be 
taken  to  avoid  giving  the  patients  pain.  We  must  also  remem- 
ber that  granulations  will  not  start  in  disorganized  tissue, 
however  clean  we  may  get  it.  The  surface  must  be  both 
healthy  and  clean.  The  ulcer  is  first  washed  with  warm  water, 
then  a  solution  of  peroxide  of  hydrogen  is  applied  until  bubbling 
ceases,  then  warm  water  must  be  used  again  to  wash  away  the 
H202.  After  we  have  a  clean  surface  a  5  per  cent,  solution  of 
cocaine  is  applied  followed  a  few  minutes  later  by  a  caustic, 
either  chromic  acid  or  carbolic  acid  or  nitrate  of  silver  and 
washed  clean  again.  The  ulcer  is  then  filled  or  covered  with 
lanoline.  The  following  day  the  washing  must  be  repeated  and 
after  applying  the  cocaine  the  slough  is  removed  by  forceps  or 
by  the  knife.  An  active  hyperemia  is  necessary  to  initiate 
healthy  granulation  and  a  mild  hyperemia  is  required  to  keep 
it  up.  Without  a  sufficient  supply  of  circulating  blood  these 
chronic  ulcers  will  not  heal.  Small  dry  cups  or  the  application 
of  hot  dry  or  moist  cloths  will  generally  bring  enough  blood  to 
the  surface  to  produce  the  required  hyperemia,  for  the  starting 
of  granulations.  But  no  granulations  will  form  if  the  surface  is 
covered  with  any  substance  which  disorganizes  tissue,  there- 
fore if  caustics  or  even  but  a  mild  bichloride  solution  has  been 
used  the  surface  must  be  washed  clean  and  if  necessary  abraded. 
A  nuclein  should  be  used  as  a  dusting  powder  to  stimulate  granu- 
lations and  the  ulcer  should  be  packed  with  an  animal  fat  pref- 
erably anhydrous  lanoline.  If  this  method  is  followed  the 
ulcer  can  be  cured,  providing  there  has  been  no  infection. 
Should  pus  continue  to  flow  in  spite  of  such  repeated  wash- 
ing showing  a  more  extensive  or  a  general  infection,  serum 
treatment  may  be  necessary  before  local  treatment  will  be 
effective. 

(Note. — Nuclein   containing   sugar   of   milk  is  intensely  ir- 
ritating.) 


246  PATHOLOGICAL    OLD    AGE 

NEOPLASMS 
Benign  Growths 

Of  the  benign  growths,  warts,  nevi  and  fibromata  are  the 
most  frequent  ones  in  old  age.  (Senile  warts  and  senile  seba- 
ceous nevi,  have  been  described.)  It  is  probable  that  the  senile 
sebaceous  nevi  are  really  adenomata.  Nevi  are  almost  without 
exception  carried  over  from  earlier  life,  persist  unaltered  and 
aside  from  their  unsightliness  produce  no  distress.  Nothing 
need  be  done  for  them.  Fibroma  occur  frequently  and  may  ap- 
pear in  numbers  upon  the  neck  and  upper  part  of  the  chest, 
less  often  upon  the  face  or  extremities.  When  small  they  may 
lie  entirely  beneath  the  skin  or  project  slightly  as  circumscribed 
nodules  or  plaques;  when  larger  they  appear  as  buttons  or 
become  pendulous.  They  vary  in  size  from  a  pea  to  a  mass 
weighing  several  pounds,  are  covered  with  normal  skin,  pro- 
duce no  distress  and  if  left  alone  they  will  remain  unaltered 
after  they  have  reached  the  limit  of  their  growth.  Small 
pedunculated  growths  can  be  clipped  off  and  the  pedicle  cau- 
terized. Sessile  growths  should  be  left  alone  unless  their  size 
or  location  makes  removal  advisable.  The  surgical  procedure 
for  their  removal  depends  upon  the  preference  of  the  surgeon. 
Electrolysis,  radiotherapy,  galvanocautery,  thermocautery  or 
the  knife  can  be  employed.  Lipoma  like  fibroma  is  seen 
in  the  aged,  often  as  small  pendulous  tumors.  They  resemble 
fibroma  but  are  softer,  more  regular  in  shape  and  generally 
appear  singly  or  in  groups  of  two  or  three,  rarely  in  numbers. 
Keloid  and  xanthoma  are  rare  and  when  occurring  are  generally 
carried  over  from  earlier  life.  Keloid  may,  however,  follow  a 
traumatism.  Other  benign  growths  like  hard  warts,  mollusca 
contagiosa,  condylomata,  etc.,  rarely  or  never  occur  in  ad- 
vanced age.  In  dealing  with  benign  growths  it  must  be  borne 
in  mind  that  in  some  cases  they  become  malignant  and  that 
their  transformation  into  a  malignant  growth  sometimes  takes 
place  after  operation.  Better  results  are  apparently  obtained 
by  the  X-ray  and  Finsten  light  than  by  the  knife.  Radium 
therapy  is  still  too  uncertain  and  too  limited  in  its  distribution 
to  be  more  than  an  experimental  measure  and  the  same  applies 
to  carbonic  acid  snow.  Thiosinamin,  fibrolysin  and  scarlet 
red  have  given  good  results  in  some  cases  and  fail  completely 
in  others. 


MALIGNANT  NEOPLASMS  247 

MALIGNANT  NEOPLASMS 

The  most  important  of  the  malignant  growths  in  the  aged 
is  the  epithelioma.  It  would  serve  no  purpose  to  discuss  the 
numerous  theories  that  have  been  advanced  to  explain  the 
etiology  and  pathogenesis  of  cancer.  There  are  also  diverse 
classifications  based  upon  structure,  clinical  manifestations, 
tissue  involved,  primary  or  secondary  appearance,  etc.  The 
primary  dermal  epithelioma  originates  as  a  dermal  lesion;  the 
secondary  growth  is  due  to  an  underlying  cancer  as  of  the 
breast,  or  is  an  extension  from  a  cancer  in  some  neighboring 
tissue  as  from  a  cancer  of  the  vagina,  or  it  is  a  metastatic  lesion 
carried  by  way  of  the  lymphatics  or  blood-vessels. 

The  primary  epithelioma  is,  in  most  cases,  secondary  to 
another  affection  of  the  skin.  Bond  says  "the  complex  cell 
change  that  we  associate  with  cancer  has  been  built  up  by  vari- 
ational changes  from  the  normal  type  and  that  one  of  the  stages 
passed  through  is  represented  by  the  various  forms  of  benign 
growth." 

Epithelioma  appears  clinically  in  two  types,  a  superficial, 
mildly  malignant,  extremely  chronic  type,  and  the  other  deep, 
active,  and  rapid.  There  is  no  sharp  dividing  line  between 
the  two,  and  the  disease  may  begin  as  a  superficial  chronic 
lesion  which  after  existing  for  years  suddenly  becomes  actively 
malignant. 

The  active  form  may  find  its  seat  primarily  upon  apparently 
healthy  tissue  or  recent  trauma  or  upon  the  site  of  a  lupus, 
syphilide,  leucoplakia,  crural  ulcer  or  scar,  rarely  upon  a  senile 
keratoma  or  xeroderma.  It  usually  begins  as  a  hard  light 
colored  nodule  gradually  becoming  dark  red,  irregular  in  shape 
and  but  slightly  above  the  level  of  the  skin.  There  is  generally 
a  hyperkeratosis  and  sometimes  a  papillomatous  growth  of 
the  nodule.  A  few  weeks  or  months  later  the  surface  becomes 
eroded  and  beneath  it  there  is  a  raw  granular  or  papillomatous 
surface  which  in  some  cases  becomes  ulcerative,  in  other  cases 
there  is  a  more  or  less  rapid  growth  of  the  papillomatous  tissue 
which  soon  extends  beyond  the  surface  and  forms  the  classical 
"cauliflower  growth"  of  malignant  papilloma.  In  this  form 
of  epithelioma  the  morbid  vegetation  may  reach  the  size  of  a 
hen's  egg.     It  is  usually   spongy,   warty  and  exudes  a  foul- 


248  PATHOLOGICAL   OLD   AGE 

smelling  clear  or  sanguineous  fluid.  After  a  time  fissures  spread 
through  the  mass,  it  becomes  ulcerative  and  the  whole  mass 
turns  into  a  foul  ulcer,  penetrating  the  tissues  and  expanding 
on  all  sides.  In  cases  where  the  tissues  break  down  and  become 
ulcerated  from  the  start,  the  further  progress  is  the  same  as  in 
the  papilloma.  The  ulcer  presents  a  hard,  overhanging  border 
which  is  undermined  and  from  which  a  semiliquid  mass  con- 
taining epithelial  cells  can  be  expressed.  The  epithelioma  can 
extend  through  the  tissue  perforating  and  destroying  muscle, 
fascia  and  even  bone.  In  some  cases  the  ulcer  exudate  forms 
a  crust  which  becomes  hard  and  completely  hides  the  destruc- 
tive process  underneath.  This  form  of  epithelioma  becomes 
painful  from  the  moment  that  the  skin  is  eroded  and  the  pain 
becomes  intense  if  the  surface  is  irritated.  It  bleeds  readily 
and  the  surface  is  necrotic.  As  the  disease  progresses  the 
neighboring  lymphatic  glands  become  involved,  later  there  are 
metastatic  cancerous  ulcers,  cachexia  appears  and  the  consti- 
tutional symptoms  follow. 

The  mild  superficial  epithelioma  usually  finds  its  seat  upon  a 
senile  keratoma.  This  may  exist  for  years  before  it  is  noticed  that 
there  is  any  change  in  its  size  or  character.  In  some  cases  there 
is  nothing  more  than  a  small  superficial  nodule  perhaps  covered 
with  scales,  or  a  hard  crust  covering  an  excoriation  or  an  ulcer 
produced  perhaps  by  scratching  or  by  a  slight  blow.  This  may 
persist  for  years  without  change,  or  other  small  nodules  may 
form  about  the  site  of  the  original  lesion.  Sooner  or  later  the 
nodules  break  down  and  become  ulcerated,  the  ulcers  being  at 
first  shallow  and  small  but  gradually  extending  and  in  some 
cases  rapidly  destroying  the  underlying  and  surrounding  tissue. 
The  rodent  ulcer  thus  formed  is  at  first  painless,  later  it  becomes 
intensely  painful.  Occasionally  the  destructive  process  halts 
and  after  remaining  quiescent  for  years  starts  afresh  or  the 
ulcer  heals.  This  form  of  epithelioma  rarely  involves  the 
glands  and  produces  neither  cachexia  nor  other  constitutional 
symptoms. 

The  favored  location  of  the  deep  epithelioma  is  the  face, 
mouth,  lips,  genitals  and  anus,  while  the  mild  epithelioma  is 
generally  found  in  the  upper  part  of  the  face  about  the  eyes  or 
nose. 

Paget's  disease  of  the  nipples  and  most  epitheliomata  found 


SARCOMA  249 

in  other  parts  of  the  body  are  secondary  to  underlying  or  con- 
tiguous carcinomata.  A  class  of  malignant  growths  which 
begin  in  soft  nevi  are  sometimes  classed  as  epitheliomata, 
sometimes  as  sarcomata.  When  arising  from  pigmented  nevi 
the  growth  is  pigmented  producing  the  melanotic  carcinoma. 
It  follows  the  course  of  the  deep  epithelioma,  being  rapid  in  its 
onset  and  development  and  speedily  involving  the  lymphatic 
glands. 

The  lentigo  maligna  of  Hutchinson  begins  as  a  darkly  pig- 
mented macule  which  after  years  of  quiescence  suddenly  begins 
to  give  evidence  of  active  malignancy  and  within  a  short  time 
acts  as  an  active  epithelioma. 

The  diagnosis  of  epithelioma  is  often  difficult,  as  there  are 
several  dermatoses  presenting  similar  clinical  manifestations 
without  the  histological  characteristics,  while  the  histological 
characteristics  of  the  former  have  been  found  in  benign  growths. 
The  diagnosis  depends  upon  the  occurrence  of  both  the  clinical 
and  the  histological  findings.  A  positive  tuberculin  or  Wasser- 
man  test  does  not  exclude  a  coexisting  carcinoma.  The  only 
tuberculide  giving  similar  symptoms  is  lupus.  This  occurs 
earlier  in  life,  is  generally  composed  of  a  group  of  lesions  and 
the  border  of  the  ulcer  is  never  indurated  or  everted.  The 
syphilides  present  a  multiplicity  of  lesions,  they  do  not  spread, 
are  not  painful  and  improve  under  the  usual  treatment  for  the 
disease.  The  benign  tumors  must  be  diagnosed  by  the  histo- 
logical findings.  Sarcoma  is  more  rapid  in  its  development, 
occurs  earlier  in  life,  rarely  ulcerates  and  involves  neighboring 
tissue  or  produces  metastatic  lesions  of  the  same  variety.  As 
a  last  resort,  if  the  diagnosis  is  still  doubtful,  the  microscope 
must  decide. 

Sarcoma 

The  sarcomatous  growths  are  relatively  rare  in  the  aged. 
The  sarcoma  is  a  perversion  of  connective-tissue  cell  growth 
occurring  under  circumstances  very  much  like  an  epithelioma. 
The  growth  proceeds,  however,  much  more  rapidly.  It  begins 
as  a  small  nodule  several  of  which  appear  in  the  same  locality. 
By  increase  and  confluence  they  form  tumors,  sometimes  as 
large  as  a  hen's  egg,  and  may  appear  on  any  part  of  the  body. 


250  PATHOLOGICAL    OLD   AGE 

They  are  often  pigmented  and  painful,  sometimes  vegetations 
appear  upon  them,  occasionally  they  ulcerate.  They  may  be 
secondary  to  sarcoma  in  another  part  of  the  body,  or  primary, 
beginning  upon  the  site  of  a  traumatism  or  other  skin  lesion, 
rarely  upon  a  healthy  surface.  They  present  various  forms, 
may  be  hard  or  soft  and  show  under  the  microscope  charac- 
teristic round,  spindle-shaped  or  giant  cells.  While  not  exhibit- 
ing the  local  destructive  tendencies  of  active  epitheliomata, 
metastases  are  more  frequent,  extirpation  is  followed  by  recur- 
rence with  increased  virulence  and  the  constitutional  effects  are 
pronounced. 

Atypical  forms  of  epitheliomata  and  sarcomata  are  occasion- 
ally seen  in  the  aged,  but  a  particle  clipped  from  the  growth  and 
examined  under  the  microscope  will  generally  determine  its 
character. 

Treatment  of  Malignant  Growths. — There  is  probably  no 
pathological  condition  in  which  more  therapeutic  experiments 
have  been  made  than  in  malignant  growths.  About  everything 
known  to  have  a  caustic  or  other  destructive  action  upon  animal 
tissue  has  been  used  to  destroy  malignant  growths,  while  in- 
ternal medication  has  kept  pace  with  external  measures.  We 
have  found,  however,  no  better  method  of  dealing  with  such 
growths  than  total  extirpation  by  the  knife.  Various  measures 
have  been  employed  to  bring  about  the  destruction  of  the 
growth,  yet  none  of  them  has  been  generally  accepted.  Some 
still  adhere  to  chemical  caustics,  others  prefer  to  use  the  knife. 
Among  the  newer  measures  are  radium  emanations,  the  X-ray, 
high-frequency  Herzian  waves,  Finsten  light  fulguration  and 
Forest's  cold  cautery.  Each  has  its  supporters,  each  has 
accomplished  a  more  or  less  complete  destruction  of  the  growth, 
yet  none  has  absolutely  prevented  the  metastases,  the  involve- 
ment of  any  neighboring  glands  or  the  recurrence  of  the  growth. 
At  the  present  moment  the  tide  is  turning  toward  internal 
medication,  the  latest  method  of  treatment  being  chemotherapy. 
It  is  sought  to  obtain  "a  chemical  substance  which,  admin- 
istered by  the  mouth,  shall  exhibit  affinity  for  the  peculiar 
chemical  constitution  of  the  cancer  cell.  Granting  that  this 
affinity  produces  a  result  injurious  or  destructive  to  the  growth, 
there  at  once  ensues  a  cure  of  cancer"  (Morton).  So  far  this 
has  not  been  accomplished.     In  the  treatment  of  epithelioma 


SENILE   PSYCHOSES  25 1 

Judd  reports  about  90  per  cent,  of  cures  by  the  X-ray  but  in 
the  other  10  per  cent,  especially  in  old  persons,  the  X-ray, 
"while  it  caused  destruction  of  the  growth,  failed  to  prevent  its 
almost  immediate  recurrence."  Korbl  reports  that  of  seventy- 
three  cases  that  were  re-examined  after  X-ray  treatment, 
thirty-seven  had  a  recurrence  of  the  growth.  Moullin,  Finzi  and 
Dominici  reporting  upon  the  result  of  radium  treatment  gave 
few  favorable  results.  The  object  is  always  to  destroy  the 
growth  and  as  long  as  the  growth  is  a  purely  local  condition 
without  gland  or  constitutional  involvement,  the  simple  caus- 
tics like  chloride  of  zinc,  caustic  potash  or  soda,  acid  nitrate  of 
mercury,  lactic  acid,  etc.,  will  suffice.  Arsenic  is  still  the  most 
popular  of  this  class  of  drugs,  although  its  action  is  apparently 
not  that  of  an  escharotic  but  of  a  toxin  to  the  pathological  cells. 
The  great  danger  in  local  arsenic  medication  is  arsenical  poison- 
ing through  absorption.  This  can  hardly  be  prevented,  a  weak 
solution  or  paste  being  useless.  We  must,  therefore,  use  it  in  a 
strength  of  at  least  1  per  cent,  to  be  effective.  This,  if  used  for 
a  long  period,  produces  toxic  symptoms  and  the  treatment  must 
be  discontinued  or  replaced  by  the  use  of  escharotics.  For  deep 
growths  the  only  reliable  treatment  is  early  and  complete  exci- 
sion. Some  surgeons  go  further  and  excise  neighboring  lym- 
phatic glands.  Even  this  generally  fails,  if  the  growth  is  a 
sarcoma,  as  metastatic  growths  almost  invariably  follow.  At 
present  we  have  no  means  of  combating  this  form  of  growth  and 
all  that  can  be  done  is  to  destroy  the  growths  as  they  appear, 
relieve  symptoms  and  maintain  the  strength  of  the  individual. 
It  is  only  in  the  superficial  forms  of  epithelioma  that  we  may  be 
reasonably  certain  of  effecting  a  permanent  cure.  In  the 
deeper  lesions,  especially  after  glandular  involvement,  operative 
intervention  may  give  temporary  relief,  but  it  rarely  prevents 
a  return  of  the  disease.  The  one  imperative  rule  in  all  cases 
is  to  remove  the  growth  completely  as  soon  as  its  character  is 
established. 

SENILE  PSYCHOSES 

Psychic  disorders  occur  frequently  in  the  aged.  Senile  de- 
mentia is  by  far  the  most  prevalent,  being  in  many  cases  second- 
ary to  other  disorders,  and  generally  the  terminal  stage  of  all 


252  PATHOLOGICAL   OLD   AGE 

mental  diseases  that  are  carried  over  from  earlier  life.  The  pri- 
mary apathetic  senile  dementia  occurring  as  the  end  result  of  the 
normal  senile  degeneration  of  the  brain  and  of  cerebral  softening 
has  been  described  under  those  heads.  Secondary  forms  are 
described  by  some  authorities  as  agitative  senile  dementia 
occurring  during  or  following  mania,  paranoiac,  melancholic, 
hypochondriac,  etc.,  senile  dementia.  Other  forms  of  senile 
dementia  are  due  to  traumatism,  apoplexy,  or  arteriosclerosis, 
and  the  terminal  dementias  of  other  psychoses.  In  the  second- 
ary dementias  the  primary  psychosis  gradually  becomes  milder 
in  its  manifestations  while  the  intellect  becomes  duller  and 
duller  until  mentality  is  completely  obliterated.  Senile  de- 
mentia whether  primary,  secondary  or  terminal  is  progressive 
and  incurable. 

Acute  senile  dementia  described  by  Salgo  consists  of  a  rapid 
dementia  following  acute  manifestations  of  mental  impairment, 
dulling  of  the  intellect,  incoherence  and  confusion,  loss  of 
memory,  etc.,  with  constant  restlessness.  These  are  accom- 
panied by  visceral  disorders,  insomnia,  and  rise  in  temperature. 
It  may  clear  up  or  the  dementia  may  become  progressively 
deepening. 

Amentia,  senile  delirium  or  hallucinatory  confusion  is  occa- 
sionally met  with.  This  generally  begins  with  rapid  confusion, 
loss  of  orientation  and  great  restlessness,  followed  by  illusions, 
delusions,  hallucinations  and  phobias,  the  patient  is  excited  and 
violently  active,  with  periods  of  comparative  quiet  during 
which  the  mental  phenomena  are  milder  and  the  restlessness 
disappears.  There  may  be  delusions  of  persecution  or  of 
grandeur,  violent  outbursts  or  depression.  In  many  cases  the 
reflexes  are  exaggerated,  pupils  irregular,  there  is  a  weak  irregu- 
lar, rapid  pulse,  fever,  constipation,  and  icterus.  Albumin  and 
indican  are  found  in  the  urine.  Amentia  may  terminate  in 
dementia,  occasionally  it  is  the  precursor  to  a  hemiplegia. 
Recovery  is  rare  in  the  aged.  While  the  violent  symptoms  may 
abate  there  is  a  progressive  dulling  of  the  intellect  until  demen- 
tia is  complete.  A  form  of  senile  delirium  sometimes  occurs 
during  the  senile  climacteric. 

Hypochondria  and  melancholia  are  so  frequently  associ- 
ated and  so  intimately  connected  in  the  aged  that  they  will 
be  considered  together.     The  melancholia  may  follow  a  neuras- 


MELANCHOLIA 


253 


thenia,  psychasthenia  or  hypochondria  or  it  may  be  a  primary 
condition  due  to  some  powerful  emotion.  Hypochondria  also 
may  be  primary  or  secondary  to  a  neurasthenia  or  psychas- 
thenia. There  may  be  emotional  depression  without  impair- 
ment of  the  intellect  or  such  mental  impairment  as  is  usual  with 
the  normal  senile  degeneration,  but  there  are  always  unnatural 
fears,  or  a  haunting  anxiety  without  a  definite  object.  In  some 
cases  there  is  a  fear  of  disease,  of  death  or  future  punishment 
for  insignificant  misdoings.  The  hypochondriac  is  given  to  in- 
trospection and  to  self-examination  of  his  physical  condition. 
The  discovery  of  an  abnormal  feature,  a  macule  or  papule,  a 
slight  rise  in  the  rate  of  respiration  or  pulse  rate  will  suffice  to 
arouse  the  most  agonizing  fear  of  disease,  culminating  in  melan- 
cholia. Slight  symptoms  are  exaggerated  and  suggestion  or 
mimicry  will  give  rise  to  imaginary  symptoms  and  sensations. 
In  some  cases  it  will  be  possible  to  explain  away  symptoms,  but 
in  most  cases  the  efforts  of  the  physician  to  quiet  the  patient's 
fears  are  looked  upon  with  suspicion.  When  melancholia  super- 
venes it  is  impossible  to  make  the  patient  realize  the  absurdity 
of  his  ideas  and  fears,  but  it  is  often  possible  in  an  early  stage  of 
melancholia  to  make  him  forget  them.  He  will  greet  the 
physician  with  numerous  complaints  and  the  latter,  if  tactful, 
will  turn  the  patient's  thoughts  to  other  subjects.  He  will 
forget  then  his  ailments  and  may,  when  reminded  of  them, 
forget  their  location. 

Senile  melancholia  may  appear  in  an  apathetic,  depressive 
form  or  in  a  restless,  agitated  one.  In  the  apathetic  form  the 
patient  will  sit  for  hours,  apparently  indifferent  to  his  surround- 
ings, complaining,  mumbling  or  weeping.  In  the  agitated 
form  the  patient  is  restless,  excited,  anxious,  fearful,  and  some- 
times violent.  In  the  violent  state  he  may  commit  murder  or 
suicide.  In  some  cases  there  are  remissions  during  which  the 
patient  is  comparatively  free  from  the  mental  and  emotional 
depression  but  each  attack  leaves  the  mental  faculties  more 
impaired  and  finally  the  patient  sinks  into  a  dementia  which  is 
progressively  deepening. 

Treatment. — In  the  treatment  of  senile  psychoses  we  must 
bear  in  mind  the  presence  of  senile  degeneration  of  the  brain 
with  the  certainty  of  present  or  ultimate  senile  dementia.  The 
keynote  of  treatment  is  psychic  stimulation.     This  is  opposed 


254  PATHOLOGICAL   OLD    AGE 

to  the  generally  accepted  method  of  treating  psychoses  by  seda- 
tives, rest  and  quiet.  When  there  is  much  restlessness,  warm 
baths  should  be  employed  and  if  these  fail  we  may  resort  to  the 
bromides.  Mental  confusion  is  best  treated  by  powerful  but 
harmonious  sensuous  impressions  which  will  attract  and  hold 
the  patient's  attention.  An  old  familiar  air  will  sometimes  dis- 
pel the  confusion  and  this  is  one  of  the  most  effective  means  for 
stimulating  memory  and  quieting  an  excited  patient.  It  is 
often  possible  to  reason  with  a  patient  while  his  mind  is  so 
diverted.  In  some  cases  the  conversion  of  the  subject  of  an 
hallucination  into  the  reality,  unknown  to  the  patient,  will 
restore  reason.  A  patient  who  nightly  saw  a  ghost  at  the  foot 
of  his  bed  was  cured  of  this  hallucination  when  one  of  his 
friends  suddenly  appeared  at  the  foot  of  the  bed,  covered  with 
a  sheet,  then  threw  off  the  sheet  and  spoke  to  the  patient. 
Sometimes  a  powerful  impression  will  destroy  an  illusion, 
delusion,  hallucination  or  phobia.  The  following  is  a  typical 
example.  The  patient  aged  sixty-nine  who  had  been  an  ardent 
fisherman  in  his  earlier  years,  was  suffering  from  arthrosclerosis 
of  the  ankles  and  shoulders.  He  had  been  treated  for  chronic 
rheumatism,  but  the  condition  grew  worse  and  he  feared  that 
his  joints  would  all  grow  stiff  and  he  would  become  like  the 
ossified  man  he  had  seen  in  a  museum.  From  this  fear  he  de- 
veloped the  dread  that  he  would  become  a  burden  to  his 
family  and  that  they  were  anxious  to  get  rid  of  him.  He  then 
developed  the  apathetic  form  of  melancholia.  Some  of  his 
friends  took  him  then  upon  a  fishing  boat  and  a  line  was  placed 
in  his  hands.  At  first  he  was  indifferent  to  his  surroundings  until 
there  was  a  sudden  tug  upon  his  line.  He  was  startled  for  a 
moment  but  as  soon  as  the  line  was  passing  through  his  hand  he 
grasped  it  and  pulled  in  his  fish.  He  continued  fishing  and 
returned  home  in  a  cheerful  spirit  and  cured  of  the  melancholia. 
Notwithstanding  the  benefit  of  change  of  environment  and 
the  constant  attention  of  physicians  and  nurses,  incarceration 
in  an  asylum  is  perhaps  the  worst  possible  treatment  for  senile 
psychoses.  The  association  of  the  senile  dement  with  other 
insane  persons  will  not  improve  him  mentally  but  may  produce 
mental  perversion  in  addition  to  mental  weakness.  Such  patients 
need  constant  diversion  and  mental  stimulation,  not  rest  and 
quiet.     Mental  agitation  requires  stimulation  of  a  different  sort 


MODIFIED   PSYCHOSES  255 

and  the  more  intense  the  excitement  the  more  intense  the  stimu- 
lation must  be.  A  brass  band  playing  a  loud  patriotic  air  will 
attract  attention  where  a  violin  solo  will  have  no  effect;  the 
harmonious  movements  of  a  large  ballet  will  quiet  the  mind 
while  the  confused  movements  of  dancers  in  a  ball  room  will  dis- 
concert and  irritate  the  patient.  A  large  well-drilled  chorus 
presenting  pleasing  stage  pictures  will  relieve  melancholy  and 
depression  and  will  calm  mental  agitation  by  substituting 
another  form  of  mental  stimulation.  Aural  stimulation,  espe- 
cially by  old  familiar  airs,  is  more  effective  than  visual 
stimulation  unless  the  latter  can  be  prolonged  and  the  interest 
maintained.  The  stimulation  may  be  prolonged  until  brain 
fag  sets  in  when  the  patient  will  fall  asleep.  Medication  must 
have  the  same  purpose  as  the  psychic  measures,  mental  stimu- 
lation. The  only  drug  suitable  in  these  cases  is  phosphorus 
given  in  1/50-grain  doses  three  times  a  day. 

MODIFIED  PSYCHOSES 

General  paresis  is  rare  in  the  aged.  When  it  does  occur  it 
does  not  give  the  clearly  defined  clinical  picture  that  it  presents 
in  maturity  and  it  may  be  mistaken  for  senile  dementia.  In 
general  paresis  in  the  aged  the  delusions  of  grandeur  are  less 
florid  than  in  maturity,  but  they  appear  early  and  thereby  dis- 
tinguish this  disease  from  senile  dementia.  There  may  be 
delusions  of  grandeur  in  the  delirious  form  of  senile  dementia, 
but  these  are  generally  combined  with  unsystematized  delusions 
of  persecution,  phobias,  and  weakened  intellect.  General 
paresis  in  the  aged  develops  more  rapidly  but  the  apoplecti- 
form attacks  occur  less  frequently  than  in  maturity.  There  is 
the  same  difficulty  in  the  speech,  which  is  rapid  and  irregular, 
the  patient  sometimes  hesitating,  at  other  times  tripping,  run- 
ning one  word  into  the  next  without  a  break  between  them,  or 
suppressing  words  or  syllables.  The  paresis  and  paralysis  of 
the  extremities  occur  at  irregular  intervals  and  clear  up  partially, 
but  each  apoplectiform  seizure  leaves  the  patient  mentally  and 
physically  weaker  than  before.  There  is  no  known  treatment 
for  this  condition. 

Mania  is  rare  except  in  the  maniacal  outbursts  of  delirious 
senile  dementia,  in  the  form  of  a  few  monomanias  peculiar  to 


256  PATHOLOGICAL    OLD    AGE 

the  aged,  as  oikeiomania,  and  in  circular  insanity.  There  are 
generally  delusions  of  grandeur  and  morbid  impulses  arsing  there- 
from, the  latter  being  often  immoral  or  criminal.  There  is  a 
disregard  of  consequences  to  others  and  of  retribution  or  punish- 
ment to  himself.  Mental  agitation  is  pronounced.  Mania  in 
the  aged  sometimes  disappears  for  months,  sometimes  reappear- 
ing without  apparent  cause  and  in  a  more  aggravated  form. 
Some  cases  are  succeeded  by  amentia  or  dementia.  Mania 
alternating  with  melancholia  and  lucid  intervals  characterize 
circular  insanity.  Such  cases  are  occasionally  met  with  in 
melancholia  when  some  insignificant  mental  or  physical  irri- 
tation will  cause  a  maniacal  outburst  sometimes  lasting  for 
days,  followed  by  exhaustion.  During  this  period  the  mind 
is  apparently  clear  but  mental  depression  follows  and  the  cycle 
is  resumed.  In  rare  cases  the  melancholia  follows  mania,  the 
latter  following  a  clear  period.  There  is  frequently  a  history 
of  early  mental  disorder,  hysteria,  neurasthenia  or  other  neuro- 
sis. Senile  paranoia  with  delusions  of  persecution  occurs  fre- 
quently, yet  it  is  seldom  recognized.  In  most  cases  the  sense 
of  hearing  is  lessened  and  the  patient,  realizing  his  diminished 
usefulness,  becomes  suspicious  when  conversation  which  he 
cannot  hear  is  conducted  in  his  presence.  This  gives  rise  to 
delusions  of  persecution,  the  patient  fearing  that  those  who  have 
the  charge  of  looking  after  him  are  anxious  to  put  him  out  of  the 
way.  Delusions  of  smell  and  taste  arise  from  the  fear  of  being 
poisoned  and  auditory  and  visual  illusions  develop  from  other 
fears.  The  patient  exaggerates  his  own  importance  until  his 
ideas  about  himself  assume  the  shape  of  delusions  of  grandeur 
and  while  boasting  of  his  strength  and  ability  to  stand  pain, 
he  will  complain  of  the  intense  pain  associated  with  insignificant 
hurts.  In  some  cases  this  is  due  to  the  desire  to  arouse  sympathy, 
generally,  however,  to  hypochondria. 

When  the  fear  of  persecution  is  directed  to  a  member  of 
the  family  there  is  generally  a  substantial  basis  which  in  itself 
is  trivial,  such  as  momentary  absence,  food  too  hot  or  too  cold 
or  too  salty,  a  sharp  reply  or  reproof,  etc.  The  patient  broods 
over  this,  exaggerates  its  importance,  and  develops  suspicion 
and  hatred,  fear  is  aroused  and  this  is  converted  into  delusions 
of  persecution.  The  fear  that  his  enemy  may  kill  him  if  he 
utters  any  complaints  will  prevent  the  patient  from  expressing 


SENILE   PSYCHASTHENIA  257 

his  fears  and  the  first  intimation  of  the  patient's  mental  condition 
may  come  when  his  will  is  read.  The  tactful  physician  will 
often  be  able  to  obtain  the  confidence  of  his  patient  sufficiently 
to  elicit  paranoiac  delusions,  although  he  will  not  be  able  to 
remove  them.  A  querulent  form  of  paranoia  is  met  with 
occasionally  after  the  senile  climacteric  and  as  mental  de- 
cadence proceeds  the  complaining  and  whining  gradually  give 
way  to  a  mumbling  dementia. 

SENILE  PSYCHASTHENIA 

Psychasthenia  or  mental  exhaustion  is  generally  associated 
with  neurasthenia.  Owing  to  the  failure  to  differentiate  be- 
tween the  two  conditions,  psychasthenia  is  usually  considered 
as  the  cerebral  phase  of  neurasthenia.  Psychasthenia  may, 
however,  exist  without  nervous  exhaustion  or  weakness  but  will 
give  symptoms  of  the  latter.  When  the  impulses  originating 
in  the  brain  are  weakened  they  are  carried  more  slowly  and  with 
less  force,  by  the  nerves  and  thus  the  nervous  symptoms  are 
produced.  Occurring  in  the  aged  it  presents  slight  differences 
from  the  similar  condition  of  maturity. 

Etiology. — Psychasthenia  is  due  to  excessive  mental  activity 
with  insufficient  repair  and  to  the  probable  absorption  of  the 
waste  products  of  mental  activity.  It  occurs  most  frequently 
in  those  engaged  in  exciting  mental  work,  especially  where  rapid 
action  or  mental  concentration  is  involved,  hence  we  find  it 
frequently  in  professional  men,  writers,  ministers,  physicians, 
and  scientists,  in  those  who  must  calculate  and  reason  quickly 
as  brokers  and  others  engaged  in  buying  and  selling  without 
long  deliberation,  in  bookkeepers,  etc.  It  occurs  generally 
when  there  has  been  a  period  of  intense  mental  activity  follow- 
ing a  period  of  rest.  After  mental  deterioration  has  begun  in 
the  aged,  even  slight  excitement  will  suffice  to  produce  brain 
fag  and  if  this  excitement  continues  brain  exhaustion  may 
result. 

Symptoms. — The  symptoms  can  be  divided  into  three  stages, 
a  preliminary  stage,  a  stage  of  brain  fag  and  a  stage  of  brain 
exhaustion. 

During  the  preliminary  stage  the  mind  is  in  a  state  of  ten- 
sion.    Ideas  whirl  or  fly  through  the  brain  and  the  individual 
17 


258  PATHOLOGICAL   OLD   AGE 

cannot  express  himself  fast  enough.  If  he  writes  he  omits  the 
last  letter  of  the  word  or  he  omits  words  altogether.  He  makes 
errors  in  calculation  by  overlooking  figures,  errors  in  speech  by- 
chopping  off  words  and  phrases.  He  does  not  take  time  to 
deliberate  where  deliberation  is  necessary,  forms  extravagant 
projects,  losing  the  sense  of  time  and  space.  In  this  period  he 
is  in  a  state  of  mental  erythrysm.  The  stage  of  brain  fag 
then  sets  in  rapidly.  It  begins  with  mental  confusion  and  head- 
ache. The  brain  feels  as  though  covered  with  a  blanket  that 
will  not  let  ideas  through.  Ideas  do  not  come  readily  and  pro- 
longed mental  concentration  becomes  impossible.  The  mind 
wanders  to  other  subjects  and  an  effort  to  keep  it  concentrated 
upon  any  one  thing  causes  a  confusion  of  ideas.  He  cannot 
keep  out  other  thoughts,  while  the  main  subject  becomes  dim 
and  may  be  forgotten.  This  stage  resembles  senile  impairment 
leading  to  dementia,  but  the  psychasthenic  can  still  evolve  grand 
conceptions,  while  in  senile  impairment  this  is  impossible  as 
the  ideas  run  along  a  lower  plane.  If  the  mental  faculties  are 
employed  during  the  stage  of  brain  fatigue  or  brain  fag,  and 
strong  efforts  are  made  to  continue  the  mental  labors,  the  stage 
of  brain  exhaustion  is  reached.  In  this  condition  thought  is  im- 
possible and  the  patient  is  really  in  a  state  of  mental  collapse. 
During  the  second  stage  the  will  becomes  weakened  and  cere- 
bral impulses  become  slower  and  weaker  and  are  conducted  less 
forcibly  by  the  nerves.  The  functional  activity  of  the  nerves 
becomes  diminished  but  not  from  lowered  functional  capacity, 
as  is  the  case  in  true  neurasthenia.  In  the  aged  psychasthenia 
hastens  the  senile  degeneration  of  the  brain  and  it  is  a  powerful 
factor  in  causing  early  senile  dementia. 

When  psychasthenia  and  neurasthenia  occur  together  they 
may  be  mistaken  for  general  paresis.  This  disease  is  rare  in 
old  age,  convulsions  may  appear  and  there  is  generally  a  feeling 
of  exhilaration  while  in  the  other  there  is  mental  depression 
and  phobias,  instead  of  delusions  of  grandeur. 

Treatment. — Mental  rest  is  the  most  important  factor  in  the 
treatment  of  psychasthenia.  While  in  neurasthenia  mental 
stimulation  is  indicated  to  dispel  the  depression,  in  psychas- 
thenia physical  exercise  which  does  not  required  mental  ex- 
ertion must  be  employed.  If  there  is  at  the  same  time  mental 
depression,  it  will  be  necessary  to  resort  to  mental  stimulants 


SENILE   NEURASTHENIA  259 

like  phosphorus,  small  doses  of  morphine,  cannabis  indica,  etc., 
beside  hygienic  measures,  such  as  change  of  environment,  out- 
door sports,  preferably  hunting  and  fishing  with  a  cheerful  com- 
panion. The  use  of  aphrodisiacs  recommended  in  the  mental 
depression  of  neurasthenia  is  contraindicated  in  psychasthenia, 
since  the  latter  is  usually  followed  by  senile  dementia  in  which  an 
abnormal  recrudescence  of  sexual  desires  frequently  occurs  and 
gives  rise  to  sexual  perversions. 

SENILE  NEURASTHENIA 

The  term  neurasthenia  is  applied  loosely  to  a  number  of 
symptoms  arising  from  constant  and  excessive  brain  and  nerve 
fatigue.  The  term  should  be  applied  only  to  the  condition  of 
nerve  weakness  and  not  to  the  mental  depression  that  accom- 
panies it  and  is  usually  due  to  it,  nor  to  the  purely  psychic 
phenomena  of  mental  exhaustion  which  are  described  as  psychas- 
thenia. This  psychasthenia  is  responsible  for  many  symptoms 
that  are  also  found  in  neurasthenia.  Both  conditions,  neuras- 
thenia and  psychasthenia,  frequently  exist  at  the  same  time. 
Neurasthenia  in  the  aged  presents  some  peculiarities  due  to 
the  generally  diminished  functional  capacity  and  activity. 

Etiology. — Neurasthenia  is  due  to  excessive  nervous  activity 
with  insufficient  repair  and  in  addition  probably  to  an  auto- 
intoxication from  the  absorption  of  waste  products  arising  from 
nerve  activity.  We  find  a  similar  condition  when  muscle  is 
employed  after  fatigue  sets  in.  A  local  toxemia  makes  further 
activity  difficult  and  finally  impossible.  When  this  point  is 
reached  we  get  muscle  exhaustion.  In  neurasthenia  the  point 
of  complete  nervous  exhaustion  is  rarely  reached  as  the  mental 
depression  and  psychasthenia  prevent  further  nervous  activity 
as  soon  as  nerve  fatigue  is  felt.  Under  some  extraordinary 
impulse  the  neurasthenic  is  able  to  exhibit  some  nervous  energy, 
which  would  be  impossible  in  complete  exhaustion. 

Nerve  weakness  generally  follows  prolonged  excitement 
whether  of  business  or  pleasure,  with  improper  recreation  or 
insufficient  exercise.  It  does  not  occur  in  those  engaged  in 
physical  labors  unless  the  character  of  the  work  necessitates 
frequent  responses  to  sudden  nerve  impulses.  The  telegraphic 
operator  waiting  for  orders  which  must  be  instantly  transmitted, 


260  PATHOLOGICAL   OLD    AGE 

the  telephone  switch  board  operator,  the  type  writing  operator, 
and  all  who  must  be  on  the  alert  for  work  requiring  rapid  action, 
are  liable  to  neurasthenia.  In  the  aged  such  nerve  tension 
causes  rapid  nerve  weakness  and  the  symptoms  appear  early 
since  the  realization  of  advancing  age  is  itself  depressing,  caus- 
ing introspection  and  the  recognition  of  failing  powers.  The 
sense  or  feeling  of  weakness  is  exaggerated,  while  under  a  proper 
stimulus  the  aged  person  will  exhibit  remarkable  nervous 
energy.  Predisposing  factors  are  heredity,  alcoholism,  early 
excesses,  worries  and  other  causes  of  mental  depression,  dis- 
turbed circulation,  toxemias  and  arteriosclerosis.  The  nervous 
or  neurotic  disposition  in  which  there  is  excessive  nervous 
irritability  is  the  underlying  factor  found  in  most  cases.  It  is 
very  rare  in  females. 

Symptoms. — In  the  aged  the  symptoms  of  neurasthenia  are 
always  accompanied  by  mental  depression  and  the  latter  is 
frequently  more  marked  than  the  nervous  symptoms.  In 
many  cases  the  mental  depression  which  ensues  as  the  result  of 
the  recognition  of  the  waning  mental,  physical  and  sexual 
powers,  causes  a  diminution  of  will  and  energy  and  the  aged 
person  exaggerates  his  loss  of  power  and  nervous  energy.  This 
pseudoneurasthenia  is  a  form  of  malingering.  If  there  is  a  real 
neurasthenia  present  there  will  be  the  intention,  but  not  the 
impulse  to  perform  the  intended  act.  The  patient  feels  con- 
stantly tired  and  even  the  slightest  task  is  performed  under 
protest.  Where  he  had  been  previously  mentally  alert  and 
physically  active  he  is  now  dull  and  apparently  lazy.  His 
movements  are  sluggish  and  are  performed  with  an  effort.  A 
sudden  danger  will  rouse  him  to  activity  but  he  soon  relapses 
into  a  state  of  mental  and  physical  depression.  Neuroses  of 
various  organs  are  often  found.  Nervous  dyspepsia  is  gener- 
ally present,  with  anorexia,  thirst,  gastric  and  intestinal  indiges- 
tion, constipation,  while  diarrhea  occurs  upon  slight  emotional 
excitement.  Cardiac  neuroses  are  frequently  observed  and 
vasomotor  disturbances  may  occur.  In  spinal  neurasthenia 
there  is  a  feeling  of  weakness  along  the  spine  and  tender  points 
are  found  upon  pressure  along  the  spinal  column.  Other 
nervous  symptoms  occasionally  observed  are  neuralgia,  paras- 
thesia,  fine  tremors,  etc.  Headache  or  hemicrania  is  some- 
times present  and  various  disorders  of  the  special  senses  may 


SENILE   NEURASTHENIA  26 1 

occur.  In  the  senile  cases  it  is  often  difficult  to  decide  whether 
some  of  the  symptoms  are  due  to  neurasthenia  or  to  arterio- 
sclerosis or  to  other  senile  changes.  The  mental  symptoms 
are  irritability,  depression,  introspection,  phobias,  etc.  The 
aged  patient  watches  his  pulse  and  notes  every  change  in  fre- 
quency or  rhythm,  he  observes  his  breathing,  his  skin,  etc., 
indeed  his  mind  is  centered  upon  himself  and  the  minutest 
change  causes  him  to  fear  the  worst.  The  morbid  depression 
and  fear  of  death  lead  to  hypochondriasis  which  later  resolves 
itself  into  a  melancholia,  this  terminating  in  dementia. 

Senile  neurasthenia  is  a  serious  condition  as  there  is  gener- 
ally a  cerebral  arteriosclerosis  present  which  cannot  be  cured, 
its  symptoms  are  persistent,  and  the  mental  state  tends  to 
melancholia  and  dementia.  If  psychasthenia  coexists  with 
neurasthenia  the  depression  soon  gives  way  to  senile  dementia. 

Neurasthenia  can  be  divided  into  four  stages,  an  irritable 
period  preceding  the  period  of  fatigue,  the  stage  of  nerve  fatigue, 
the  period  following  fatigue  and  preceding  exhaustion  and  the 
stage  of  exhaustion.  During  the  preliminary  period  the  indi- 
vidual exhibits  physical  irritability.  Like  the  man  with  his 
finger  on  the  trigger  waiting  for  the  command  to  fire,  the  patient 
is  ready  to  jump  or  start  upon  the  slightest  provocation.  He 
does  things  rapidly  when  there  is  no  necessity  for  speed,  makes 
unnecessary  movements  and  is  in  a  state  of  nervous  tension. 
In  the  stage  of  fatigue,  he  moves  slowly  and  with  deliberation 
and  avoids  unnecessary  activity.  In  this  stage  mental  depres- 
sion appears  and  tends  to  inhibit  motion.  There  is  still  some 
irritability  with  occasional  outbursts  of  speed  or  exaggerated 
energy.  If  this  is  persisted  in  the  stage  of  fatigue  is  followed  by 
the  intermediate  period.  Now  it  requires  a  sensible  effort  and 
a  strong  impulse  to  arouse  nervous  energy.  In  this  stage  the 
local  neuroses  appear,  introspection  becomes  marked  and  we 
find  the  host  of  symptoms  described.  The  stage  of  complete 
nervous  exhaustion  is  rarely  reached.  In  this  stage  there  is 
complete  loss  of  energy,  motion  and  even  eating  becomes  an 
effort.  It  may  occur  if  under  some  powerful  stimulus  during 
the  preceding  period  some  extraordinary  effort  is  made.  This 
stage  ends  in  collapse.  There  is  no  sharp  dividing  line  between 
the  stages,  the  first  passing  rapidly  into  the  second,  the  second 
passing  slowly  into  the  third.     The  onset  of  the  last  may  be 


262  PATHOLOGICAL   OLD   AGE 

sudden.  Aged  persons  generally  seek  medical  aid  when  the 
stage  of  fatigue  sets  in;  younger  individuals  make  efforts  to 
continue  their  work  until  this  stage  is  well  advanced. 

Treatment. — The  most  important  indication  in  the  treat- 
ment of  senile  neurasthenia  is  to  improve  the  mental  condition. 
This  can  be  done  most  effectively  by  the  use  of  aphrodisiacs 
and  a  favorable  result  will  have  a  more  potent  beneficial  effect 
upon  an  aged  man  than  any  other  stimulus.  Change  of 
scene,  mental  diversions,  hobbies,  out-door  amusements,  are 
all  beneficial.  There  must,  however,  always  be  a  cheerful 
companion  to  prevent  a  lapse  into  the  habit  of  introspection. 
A  day's  fishing  when  fishing  is  good  will  rouse  nervous  energy 
and  dispel  mental  depression,  while  quiet,  rest,  and  the  compan- 
ionship of  fellow  sufferers  in  a  sanitarium  will  not  cure  mental 
depression  or  neurasthenia.  For  the  physical  condition  we 
can  use  strychnine,  caffeine  or  arsenic,  salt  water  baths  and 
static  electricity.  Pleasurable  excitement  which  will  keep  the 
mind  occupied  but  will  not  confuse  should  form  part  of  the 
routine  treatment.  There  is  probably  nothing  more  effective 
to  take  the  mind  away  from  thoughts  of  the  body  than  an  old 
familiar  air. 

Insomnia,  especially  insufficient  sleep  at  night,  is  not  alone 
distressing;  it  invariably  causes  introspection  with  phobias.  A 
hot  bath  or  foot  bath  should  be  tried,  hot  malted  milk  taken 
before  going  to  bed  and  if  these  fail  we  must  give  veronal  or 
trional  in  5-  to  10-grain  doses. 

SENILE  EPILEPSY 

Senile  epilepsy  is  a  disease  of  old  age  only  in  so  far  as  the 
ordinary  epilepsy  of  earlier  life  may  occur  in  the  aged.  Cases 
originating  in  old  age  present  minor  clinical  differences,  but  as 
these  differences  are  ascribed  to  a  coexisting  arteriosclerosis 
some  authorities  speak  of  it  as  arteriosclerotic  or  cardiovascular 
epilepsy. 

Etiology. — While  neither  the  etiology  nor  the  pathology  has 
been  determined,  in  nearly  every  case  one  of  the  supposed  causes 
of  early  life  can  be  found.  It  may  be  an  infectious  disease, 
intoxication  or  autointoxication,  powerful  emotion,  sexual 
excesses,  traumatism  or  some  cerebral  disease.     In  some  cases 


SENILE   EPILEPSY  263 

no  cause  can  be  assigned  and  these  are  called  idiopathic  senile 
epilepsy.  It  is  probable  that  in  every  case  there  is  an  irritation 
of  some  portion  of  the  cerebral  cortex  which  contains  a  focus  left 
from  some  former  cerebral  disease.  The  irritation  may  come 
from  blood  toxins  as  in  alcoholism,  syphilis,  nicotine  or  tubercu- 
losis or  from  traumatism  or  a  sudden  emotion,  etc.  It  is  uncer- 
tain what  the  relation  between  senile  epilepsy  and  arterioscle- 
rosis is,  but  it  is  generally  conceded  that  the  vascular  condition 
may  produce  the  neurosis. 

Symptoms. — Senile  epilepsy  possesses  the  pathognomonic 
element  of  suddenness.  The  first  attack  is  generally  as  severe  as 
later  ones.  The  cry  is  frequently  absent,  but  there  are  occa- 
sional premonitory  symptoms,  as  headache,  spasms,  neuralgic 
pains,  vertigo  and  frequently  an  aura.  The  convulsions  are 
generally  less  severe  and  not  as  prolonged  as  in  maturity.  In 
other  respects  the  convulsive  seizure  does  not  differ  from  that  of 
maturity.  The  mind  is,  however,  frequently  affected  and  after 
several  attacks  dementia  is  liable  to  set  in  with  progressive  loss 
of  mentality.  It  is  hardly  possible  to  mistake  epilepsy  for  any 
other  disease  having  convulsions.  The  convulsion  of  uremia  is 
generally  followed  by  coma  and  there  is  a  history  of  renal  dis- 
ease. In  apoplexy  there  is  paralysis,  meningitis  is  very  rare  in  the 
aged  and  there  is  generally  some  paralysis,  headache,  mental  dis- 
turbance, fever,  irregular  pupils,  etc.  Hysteria  is  rare  in  the  aged 
and  there  is  generally  a  history  of  daily  attacks  with  emotional 
perversions,  the  attack  ending  in  a  flood  of  tears.  In  general 
paralysis,  the  disturbance  of  speech  and  the  mental  condition 
will  serve  to  distinguish  it. 

Epileptiform  convulsions  can  be  produced  by  interfering 
with  the  cerebral  circulation,  as  when  compressing  the  carotids. 
In  these  cases  there  are  clonic  spasms  but  no  aura,  no  cry, 
the  sphincters  are  not  relaxed,  coma  comes  on  gradually,  there 
is  no  deep  sleep  after  the  attack  and  there  is  no  mental  impair- 
ment. In  senile  epilepsy  the  tonic  spasm  lasts  but  a  moment, 
the  clonic  spasms  are  weaker,  the  legs  are  not  thrown  about 
as  in  younger  life,  and  the  sleep  is  less  profound  than  in 
maturity. 

Treatment. — The  treatment  is  as  in  maturity.  The  under- 
lying cause  must  be  treated.  If  no  cause  can  be  found  we  must 
fall  back  upon  the  bromides,  preferably  the  bromide  of  strontium 


264  PATHOLOGICAL   OLD   AGE 

in  10-grain  doses  several  times  a  day  with  total  exclusion  of 
meat.   The  nerve  stimulants  like  strychnine  are  contraindicated. 


Neuroses  in  the  Aged 

The  aged  frequently  present  nervous  phenomena  for  which 
no  cause  or  pathological  change  can  be  found. 

(Some  of  these  like  epilepsy  and  neurasthenia  present  marked  peculiarities  and 
are  placed  among  the  modified  diseases.  Others  like  senile  tremor  and  senile 
abasia  are  probably  manifestations  of  senile  changes  of  the  cord  and  are  classified 
accordingly,  while  under  senile  neuroses  will  be  placed  various  neuralgias  and 
other  neuroses  that  are  rare  or  unchanged.) 

Hysteria  is  extremely  rare  in  the  aged  and  does  not  differ 
from  the  same  disease  in  maturity.  Cases  may  be  carried  over 
from  earlier  life  or  follow  traumatism,  the  latter  cause  producing 
at  times  extreme  depression  and  any  of  the  numerous  manifesta- 
tions of  hysteria.  Large  doses  of  bromides  and  narcotics  may 
be  required  to  quiet  the  patient.  In  giving  narcotics  in  these 
cases  they  should  be  combined  with  respiratory  and  cardiac 
stimulants. 

Hemicrania  or  migraine  is  of  rare  occurrence  in  the  aged  and 
is  then  usually  carried  over  from  maturity.  It  is  really  a  dis- 
ease which  becomes  milder  and  finally  disappears  with  advancing 
years  and  when  it  does  occur  it  is  either  a  symptom  of  cerebral 
arteriosclerosis  or  a  prodromal  symptom  of  some  serious  cere- 
bral or  nervous  disturbance.  It  may  precede  apoplexy  or 
mental  breakdown.  When  occurring  as  a  prodromal  symptom 
it  is  usually  associated  with  irritability,  anxiety,  nausea,  vertigo 
and  other  nervous  phenomena.  The  treatment  depends  upon 
the  cause.  For  the  relief  of  the  headache,  a  large  dose  of  bro- 
mide of  sodium  should  be  taken  and  if  the  heart  is  in  good  con- 
dition this  may  be  combined  with  one  of  the  coal  tar  prepara- 
tions like  antipyrin  or  acetphenetidin  with  caffein  or  ammonium 
carbonate. 

Chorea  is  rarely  met  with  in  the  aged  although  choreiform 
convulsive  movements  of  the  hands  are  sometimes  seen  in  the 
course  of  other  nervous  diseases  especially  in  those  of  traumatic 
origin.  Very  few  cases  of  the  chronic  Huntington's  chorea  have 
been  reported  and  these  were  invariably  associated  with  senile 
dementia.     The  ordinary  chorea  appears  generally  in  a  mild 


Tremorgraph — Chorea.     (Neustaedter,  Med.  Record,  July  17,  1909.) 


Tremorgraph — Epilepsy.     (Neustaedter,  If  erf.  Record,  July  17,  1909.) 


n/Vyv\y\/\AA/yV\AAA/v\AA^^ 


Tremorgraph — Hysterical    tremor.       (Neustaedter,    Med. 
Record,  July  17,  1909.) 


INSOMNIA  265 

form,  is  sometimes  limited  to  one  side  and  the  movements  may- 
be rhythmical.  A  one-sided  chorea  has  been  observed  preceding 
a  hemiplegia.  The  choreic  movements  are  identical  with  the 
same  movements  seen  in  childhood.  The  treatment  consists 
in  the  administration  of  arsenic  in  increasing  doses  until  the 
physiological  effects  of  the  drug  are  produced.  Chronic  chorea 
is  not  benefited  by  arsenic  or  any  other  drug. 

Diabetes  insipidus  is  sometimes  classed  as  a  neurosis,  al- 
though it  is  in  almost  every  case  a  symptom  of  a  nervous  or 
cerebral  affection.  It  occurs  most  frequently  in  connection 
with  hysteria,  epilepsy  and  neurasthenia,  follows  apoplexy  or 
traumatic  affections  of  the  brain  or  cord  and  may  be  a  temporary 
condition  following  some  strong  emotion.  The  aged  sometimes 
complain  that  they  pass  an  excessive  amount  of  urine  when 
suffering  from  dilatation  of  the  bladder.  They  have  then  a 
frequent  desire  to  urinate  and  pass  a  small  amount  each  time 
but  the  total  amount  is  not  excessive. 

The  treatment  of  diabetes  insipidus  depends  upon  the  causa- 
tive disease. 

INSOMNIA 

The  aged  frequently  complain  of  insomnia,  although  in  most 
cases  it  is  a  pseudo-insomnia  for  which  nothing  need  be  done. 
They  take  frequent  naps  during  the  day  and  are  then  unable 
to  sleep  more  than  a  few  hours  at  night.  Slight  exercise  induces 
fatigue  and  they  fall  asleep  after  their  meals  and  after  doing  a 
little  work.  Mental  exercise  brings  on  brain  fag  and  they  fall 
asleep  while  reading  the  paper,  listening  to  a  lecture  or  sermon 
or  after  an  argument  or  dispute.  In  this  way  the  aged  indi- 
vidual may  get  three  or  four  hours  sleep  during  the  day  and  his 
night's  rest  being  broken  perhaps  by  an  overdistended  bladder, 
he  complains  of  insomnia.  To  cure  this  pseudo-insomnia  it 
would  be  necessary  to  prevent  the  daylight  naps,  which  aside 
from  being  a  harsh  procedure,  would  interfere  with  recuperation 
and  repair.  The  best  that  can  be  done  in  these  cases  is  to  draw 
off  the  urine  and  give  a  hot  drink  and  a  hot  foot  bath  at  night. 
They  will  fall  asleep  more  readily  and  will  not  be  disturbed  by 
an  irritable  overfilled  bladder,  but  it  will  not  increase  the  total 
amount  of  sleep.     Drugs  are  unnecessary  in  this  condition. 


266  PATHOLOGICAL   OLD   AGE 

Real  insomnia  may  be  due  to  pain,  fever,  toxemia,  nervous 
or  cerebral  disease.  There  may  be  inability  to  fall  asleep, 
broken  sleep  or  insufficient  sleep.  The  treatment  depends  upon 
the  cause.  If  hypnotics  are  required  they  should  be  selected 
from  the  carbamide  group,  not  from  the  methane  or  chloral 
group  of  hypnotics. 

NEURALGIA 

Various  forms  of  neuralgia  occur  in  the  aged,  trifacial  neu- 
ralgia being  the  most  frequent  and  the  only  one  for  which  a 
conclusive  etiological  factor  has  been  found.  (This  is  described 
in  the  second  group.) 

Trifacial  neuralgia  may  be  due  to  other  causes  than  compres- 
sion of  the  terminal  fibers  in  the  bony  substance  of  the  lower  jaw. 
In  most  cases  it  is  secondary  to  another  local  disease  as  caries 
of  the  teeth,  disease  of  the  mucous  membrane  of  the  nose,  max- 
illa, or  frontal  sinus,  exostoses,  or  it  may  be  secondary  to  an  infec- 
tious disease,  or  it  may  be  due  to  cold,  local  irritation,  etc.  In 
some  cases  no  cause  can  be  found.  The  differentiation  of  the 
affected  branches  of  the  trifacial  nerve  depends  upon  the  loca- 
tion of  the  painful  pressure  points.  In  supraorbital  neuralgia 
this  is  found  in  the  supraorbital  notch  of  the  frontal  bone,  in 
supramaxillary  neuralgia  it  is  found  in  the  infraorbital  fora- 
men, and  in  inframaxillary  neuralgia  the  painful  pressure  point 
is  at  the  mental  foramen.  These  points  are  surrounded  by 
painful  areas.  The  pain  is  severe,  there  being  usually  a  con- 
stant dull  ache  in  the  region  of  the  affected  nerve  branch  with 
paroxysms  of  agonizing  sharp  pain  over  the  painful  pressure 
points.  In  the  treatment  of  trifacial  neuralgia  the  cause  should 
be  determined  and,  if  possible,  removed.  Supraorbital  neu- 
ralgia may  be  due  to  disease  of  the  frontal  sinus,  while  many 
cases  of  supramaxillary  and  inframaxillary  neuralgia  are  due  to 
dental  caries.  Where  the  cause  is  unknown  or  cannot  be 
removed  the  treatment  must  be  directed  to  the  relief  of  pain. 
The  injection  of  10  minims  of  a  4  per  cent,  solution  of  cocaine 
will  generally  give  temporary  relief.  Relief  and  sometimes  per- 
manent cure  is  obtained  by  alcohol  injections.  Other  local 
measures  are  morphia  and  atropia  injections,  the  application  of 
a   piece   of   cotton  soaked   in  ether,  the  ethyl  chloride  spray, 


NEURALGIA  267 

cocaine  ointment,  galvanism  and  heat.  In  extreme  cases  when 
local  measures  fail  surgical  interference  including  resection  of  the 
nerve  branch  may  become  necessary. 

Occipital  neuralgia  is  rare  in  the  aged.  It  is  generally  due 
to  sudden  exposure  to  cold,  sometimes  to  gout  or  arthritis  defor- 
mans, rarely  to  infectious  diseases.  Painful  pressure  points  are 
midway  between  the  mastoid  process  and  the  first  vertebra  and 
at  the  posterior  junction  of  the  sternocleidomastoid  muscle  and 
the  occipital  bone,  the  pain  shooting  into  the  surrounding  tissue 
and  sometimes  extending  over  the  entire  scalp.  The  neuralgic 
paroxysms  are  intense,  lancinating  and  last  but  a  moment.  The 
treatment  is  purely  local  and  consists  of  the  application  of  moist 
heat,  cocaine  ointment,  galvanism.  It  may  be  necessary  to  give 
morphine  to  secure  sleep.  Surgical  intervention  is  rarely 
necessary. 

Brachial  neuralgia  may  occur  in  the  aged  as  a  result  of  disease 
of  the  heart,  aorta  or  subclavian  artery,  of  rheumatism,  gout, 
infectious  diseases,  diabetes,  cancer,  hysteria  or  local  disease.  In 
most  cases  no  etiological  factor  can  be  found  and  the  disease  is 
classed  as  a  pure  neurosis.  There  are  usually  several  pressure 
points  where  branches  emerge  from  their  muscular  folds.  Beside 
the  paroxysmal  attacks  there  are  often  local  disturbances  such  as 
paresthesias,  herpes  zoster,  local  hyperemia  or  anemia,  these 
occasionally  alternating.  The  treatment  is  as  for  occipital 
neuralgia. 

Ischial  neuralgia  occurs  occasionally  in  the  aged  and  is  usu- 
ally due  to  sudden  changes  of  temperature  or  prolonged  stand- 
ing, sometimes  to  pressure  upon  the  nerve  by  growths,  hard- 
ened feces,  etc.,  sometimes  again  to  local  passive  congestion, 
inflammations  or  other  causes  of  neural  irritation.  Bilateral 
neuralgia  may  be  due  to  a  disease  of  the  cord  or  to  a  constitu- 
tional disease.  Painful  pressure  points  are  found  all  along  the 
ischial  nerve  and  the  pain  radiates  but  slightly.  Slight  at  the 
beginning,  the  pain  becomes  rapidly  more  severe  with  occasional 
paroxysms  of  intense  sharp  pains  lasting  but  a  moment.  Pres- 
sure and  motion  increases  the  pain,  but  the  paroxysms  occur  fre- 
quently at  night  also.  In  lying,  sitting  and  standing  the  patient 
assumes  a  posture  which  will  shield  the  affected  side  from  pres- 
sure and  motion.  The  treatment  is  as  for  occipital  neuralgia. 
In  some  cases  a  mixture  of  equal  parts  of  chloral  and  camphor 


268  PATHOLOGICAL   OLD   AGE 

pencilled  along  the  nerve  will  give  relief.  Many  of  the  drugs 
useful  in  neuralgias  in  earlier  life  cannot  be  used  in  the  aged. 
Aconitin  is  dangerous,  iodide  of  potassium  is  useless,  arsenic  and 
quinine  are  of  doubtful  value.  Alcohol  injections  are  occasion- 
ally of  benefit,  sometimes  they  produce  a  neuritis  and  local 
tissue  inflammation.  In  many  cases  we  must  resort  to  morphine 
for  temporary  relief  and  surgical  measures,  such  as  nerve  stretch- 
ing or  resection. 

PREFERENTIAL  DISEASES  OF  OLD  AGE 

The  fourth  group  includes  the  diseases  most  frequently 
found  after  middle  age  although  they  may  appear  earlier. 
Some  of  these  diseases  are  primary,  as  diabetes,  gout,  can- 
cer. The  prevalence  of  these  diseases  in  late  life  and  their 
infrequency  in  early  life  would  seem  to  indicate  some  relation 
to  the  process  of  involution.  The  secondary  diseases  of  this 
group  include  chronic  diseases  many  of  which  arise  in  old  age 
from  a  focus  left  over  from  an  earlier  acute  disease. 

CARCINOMA 

Ignorance  of  the  nature  and  pathogenesis  of  cancer  makes 
it  difficult  or  impossible  to  assign  it  to  its  proper  group.  It  is 
here  classed  as  a  preferential  disease  owing  to  its  prevalence  in 
advanced  life.  If  we  consider  it  an  infectious  disease  it  would 
be  properly  placed  among  the  infectious  diseases  of  the  fifth 
group.  If  we  accept  the  view  that  it  is  a  perversion  of  the  nor- 
mal process  of  involution  of  certain  tissues  we  would  be  obliged 
to  assign  it  to  the  first  group.  The  latter  seems  to  the  author 
to  be  the  most  plausible  explanation  of  its  origin  and  nature  and 
is  in  accord  with  the  theory  of  tissue-cell  evolution.  Cohn- 
heim's  theory  is  that  cancers  arise  from  faulty  embryonic  devel- 
opment, embryonic  cells  remaining  dormant  until  late  in  life. 
The  tissue-cell  evolution  theory  is  based  upon  analogy  with 
evolution  in  higher  and  more  complex  forms  of  life.  Atavistic 
tendencies  appear  in  all  forms  of  higher  life  and  in  all  stages  of 
evolution.  May  not  the  primitive  cells  show  the  same  tenden- 
cies? These  tendencies  would  become  more  pronounced  at 
that  stage  of  evolution  when  the  cells  are  departing  from  their 


CARCINOMA  269 

most  perfect  condition  and  their  functions  are  no  longer  best 
fitted  for  the  welfare  of  the  economy.     In  senescence,  functional 
activity  of  the  cells  is  lessened,  the  organism  becomes  function- 
ally weakened  and  the  tissues  are  altered.     If  at  this  time  there 
occurs  a  cell  traumatism  or  nutritional  perversion  which  inter- 
feres with  the  steady  progressive  cell  evolution  there  will  be  a 
change  in  the  character  and  properties  of  that  cell.     It  may 
cause  complete  destruction  of  the  cell,  or  further  impairment 
of  its  functions  or  perverse  stimulation  and  if  there  are  atavistic 
tendencies  there  will  be  a  return  to  an  earlier  type,  or  to  cells 
of  an  earlier  evolutionary  period  with  disordered  growth  and 
disordered  functional  activity.     Cancer  never  begins  en  masse, 
but  in  a  single  cell  or  in  several  adjoining  cells  possessing  similar 
tendencies.     Its  further  growth  is  by  extension  from  a  single 
focus  and  by  the  formation  of  new  foci  by  means  of  cancer  cells 
carried  in  the  blood  or  lymph  channels,  these  cells  stimulating 
cells  of  other  tissues  to  disordered  growth  or  activity.     Cancer 
is  not  a  metastatic  disease,  i.e.,  one  that  shifts  its  location  away 
from  the  original  site.     Heredity  is  probably  the  most  important 
etiological  factor  in  the  atavistic  tendencies  in  cell  life,  just  as 
it  is  in  the  life  of  the  human  being  as  a  whole.     It  is  impossible 
here  to  take  up  all  forms  of  cancer,  and  all  the  localities  in  which 
they  may  appear,  or  to  go  into  the  pathology  of  cancer  growths, 
therefore,  little  more  than  the  symptoms  and  treatment  of  the 
most  important  forms  will  be  considered  here  (the  malignant 
growths  of  the  skin  being  placed  among  the  modified  skin  dis- 
eases).    Syms  points  out  a  precancerous  stage  and  shows  that 
benign  tumors,  chronic  ulcerations,  chronic  inflammations,  scars, 
and   prolonged  irritation  are  prominent  precursors  of  cancer. 
He  quotes  Young,  who  demonstrated  an  immense  proportion 
of   carcinomas  among  cases  of  enlarged  prostate;  Bloodgood, 
who  studied  sixty-five  cases  of  pigmented  mole  which  became 
malignant;  and  Mayo  who  found  between  60  and  70  per  cent. 
of  gastric  carcinomas  on  the  sites  of  gastric  ulcers.     The  recog- 
nition of  this  precancerous  stage  would  save  many  cases  from 
the  later  ravages  of  cancer.     There  is  apparently  an  antagonism 
between  cancer  and  the  infectious  diseases.     Cancer  is  very 
rare  in  lepers  or  syphilitic  cases  or  in  malarial  districts.     A 
large  percentage  of  cancer  cases  never  had  any  infectious  disease, 
while  on  the  other  hand  erysipelas  rarely  develops  in  cancer 


270  PATHOLOGICAL    OLD   AGE 

cases.  Tuberculous  cadavers  show  cancer  in  4  per  cent.,  non- 
tuberculous  cadavers  show  cancer  in  1 1  per  cent,  of  cases. 

There  are  certain  clinical  features  common  to  all  cancers. 
The  most  prominent  is  the  cancer  cachexia,  a  rapid  emaciation, 
an  anemia  with  rapid  diminution  in  hemoglobin  percentage 
and  in  the  number  of  red  cells  and  a  muddy,  sallow  complexion, 
loss  of  strength  keeping  pace  with  the  emaciation  and  mental 
depression.  Primary  cancers  are  generally  followed  by  second- 
ary ones,  the  most  frequent  location  of  secondary  cancers  being 
in  the  lymphatic  glands,  and  where  the  primary  cancer  attacks 
an  abdominal  organ  other  than  the  liver,  the  liver  is  the  usual  seat 
of  it.  Pain  is  a  frequent  but  not  a  constant  feature.  Itisusually 
neuralgic  in  character,  and  due  to  pressure  of  the  growth  upon 
a  nerve  or  ganglion.  It  is  often  more  severe  and  persistent  in  the 
secondary  cancer  than  in  the  primary  lesion.  In  many  locations 
the  growth  can  be  neither  seen  nor  felt  but  as  it  increases  in 
size  it  presses  upon  adjoining  tissues  and  symptoms  pointing 
to  disease  of  such  tissues  appear.  This  is  a  late  feature. 
Cancer  growths  near  openings  have  a  tendency  to  grow  to- 
ward the  opening  occluding  it,  and  when  in  channels  or  tubes, 
the  tendency  of  growth  is  inward,  causing  stenosis  with  final 
complete  occlusion.  Cancer  does  not  produce  fever.  When 
there  is  fever  it  is  due  to  an  accidental  infection  or  inflammation. 

There  is  no  cure  for  cancer  except  complete  extirpation  of  the 
growth  by  surgical  means,  before  metastases  have  appeared. 
Even  then  the  relief  is  often  only  temporary,  as  foci  for 
future  growths  have  usually  been  produced.  The  character 
of  the  operation  will  depend  upon  the  findings  after  the 
growth  is  reached.  Drug  treatment  can  be  only  palliative. 
Jacobi  strongly  recommends  methylene  blue  in  doses  of  1 
grain  gradually  increased  to  3  grains  three  times  a  day,  com- 
bined with  extract  of  belladonna,  in  inoperable  carcinoma. 

Oral  Cancer. — Cancer  of  the  mouth  includes  cancer  of  the 
lip,  tongue,  cheeks,  tonsil  and  pharynx.  They  occur  most  fre- 
quently in  tobacco  smokers. 

Cancer  of  the  lip  is  usually  a  primary  epithelioma  having  its 
seat  at  the  junction  of  the  mucous  membrane  and  the  skin. 
It  begins  in  most  cases  as  a  papule  or  small,  hard  wart  which 
may  exist  without  change  for  months  or  years.     It  then  begins 


CANCER  OF  THE  TONGUE  AND  MOUTH  27 1 

to  itch  or  annoy  and  a  crust  forms.  The  patient  picks  this, 
leaving  a  slight  ulceration  which  refuses  to  heal  but  increases 
in  size  and  depth  while  the  surrounding  tissue  becomes  hard 
and  swollen.  In  some  cases  the  disease  begins  in  a  fissure  or 
a  pustule  which  later  ulcerates.  The  further  progress  of  the 
disease  follows  one  of  two  courses.  The  ulcer  may  become 
larger  and  deeper  until  it  destroys  a  large  part  of  the  lip  or 
the  lip  may  be  filled  with  a  mass  of  cancerous  tissue  forming  a 
cauliflower-shaped  hemorrhagic  tumor,  which  will  bleed  upon 
the  slightest  irritation  or  will  crack  and  become  covered  with 
foul  ulcers.  Later  the  adjoining  or  neighboring  tissues  become 
involved.  The  submaxillary  glands  are  early  affected,  becom- 
ing hard,  swollen  and  painful,  while  the  other  glands  of  the 
lower  jaw  and  the  neck  are  soon  similarly  involved.  The 
viscera,  however,  are  rarely  affected.  Cachexia  is  not  marked 
until  the  disease  is  well  advanced  but  it  then  progresses  rapidly 
and  may  cause  death  from  exhaustion.  The  only  disease  with 
which  cancer  of  the  lip  is  liable  to  be  confounded  is  syphilis. 
The  history,  the  presence  of  other  syphilides  and  the  Wasser- 
mann  reaction  will  clear  up  this  source  of  error.  The  only 
effective  treatment  is  complete  extirpation  of  the  growth  before 
glandular  involvement.  If  the  glands  are  affected  these  also 
must  be  removed.     Delay  is  fatal. 

Cancer  of  the  Tongue  and  Mouth. — Cancer  of  the  tongue  is 
usually  a  primary  epithelioma  beginning  as  an  indurated  swelling 
at  the  surface  of  the  organ.  The  swelling  is  painful  upon  pres- 
sure, neuralgic  pains  shoot  sometimes  through  it,  and  the  tongue 
can  be  protruded  with  difficulty  only,  while  swallowing  becomes 
painful.  In  some  cases  the  swelling  increases  until  the  greater 
part  of  the  tongue  is  involved,  in  others  it  ulcerates,  the  ulcer 
growing  larger  and  deeper  until  the  whole  oral  cavity  is  a  foul- 
smelling  ulcerated  mass.  The  salivary  glands  swell  and  may 
ulcerate  also.  Cachexia  sets  in  early  and  causes  death  from 
exhaustion  in  from  three  to  twelve  months.  In  some  cases 
death  is  due  to  a  deglutition  pneumonia.  The  only  treatment 
possible  in  these  cases  is  surgical.  Antiseptic  mouth  washes  and 
local  analgesic  remedies  may  be  required  for  temporary  relief 
of  the  fetor  and  pain,  and  rectal  alimentation  may  become  neces- 
sary.    The  progress  of  the  disease  cannot  be  halted  by  medicinal 


272  PATHOLOGICAL   OLD    AGE 

measures.  In  some  cases  the  cancerous  progress  begins  in  the 
mucous  membrane  of  the  cheek  as  a  small  ulcer  which  spreads 
rapidly  in  all  directions,  soon  involving  the  tongue.  In  rare 
cases  the  ulcer  burrows  through  the  cheek.  The  further  prog- 
ress is  as  in  cancer  of  the  tongue. 

The  above  description  applies  to  cancer  of  the  tonsil  also. 
A  few  cases  of  primary  cancer  of  the  parotid  gland  have  been 
recorded.  It  begins  as  a  swelling  under  the  angle  of  the  jaw, 
increasing  rapidly  in  size,  pressing  in  all  directions  and  interfering 
with  deglutition  and  occasionally  with  respiration.  The  tumor 
itself  is  not  painful  but  pressure  upon  nerves  causes  intense  pain. 
It  may  be  mistaken  for  parotitis  but  its  constant  growth  with- 
out fever  or  pain  upon  pressure  will  serve  to  distinguish  them. 
Surgical  interference  is  the  only  remedy. 

Cancer  of  the  Larynx. — This  is  usually  a  primary  epithelial 
growth;  sometimes  it  occurs  as  an  extension  of  a  carcinoma 
from  an  adjoining  tissue,  rarely  as  a  secondary  cancer.  Its 
favorite  seat  is  upon  the  vocal  cords,  though  it  may  occur 
elsewhere.  It  begins  as  a  surface  infiltration  which  forms  first 
excrescences  then  ulcerations  which  extend  in  size  and  depth. 
It  resembles  cancer  of  the  rectum  in  its  slow  development,  slow 
progress,  slight  cachexia  and  late  involvement  of  the  lymphatics. 
The  early  symptom  of  cancer  of  the  vocal  cords  is  a  persistent 
hoarseness  without  pain  or  cough.  The  laryngoscope  shows 
a  broad-based  growth  which  may  be  smooth  or  uneven,  slightly 
reddened  and  with  an  infiltrated  area  around  it  or  at  one  side. 
The  motion  of  the  affected  band  during  respiration  and  phona- 
tion  is  greatly  impaired,  thereby  differing  from  benign  growths 
in  which  the  motility  is  not  altered.  Cancer  growths  in  other 
parts  of  the  larynx  will  produce  symptoms  of  stenosis  or  pressure 
according  to  the  direction  in  which  the  growth  extends.  It  may 
cause  difficult  deglutition  or  difficult  respiration  or  pain  on 
motion,  these  symptoms  increasing  until  deglutition  or  respira- 
tion becomes  impossible.  When  ulceration  occurs  there  is  a 
mucopurulent  discharge,  later,  a  fetid  odor  of  the  breath  shows 
necrotic  changes.  Secondary  cancers  of  adjoining  tissues  fre- 
quently follow  and  their  symptoms  may  be  more  severe  than  the 
symptoms  of  the  primary  growth. 

Treatment  is  early  surgical  intervention. 


PLEURAL   CANCER 


273 


Cancer  of  the  Lung. — Cancer  of  the  lung  is  very  rare  and 
most  of  the  reported  cases  were  secondary  cancers  in  which  the 
primary  one  was  of  greater  clinical  importance.  Primary  cancer 
occurs  only  by  extension  of  a  carcinoma  of  the  finer  bronchial 
tubes  along  the  bronchioles  and  alveoli  into  the  lung  tissue.  The 
tissue  first  becomes  hard  then  breaks  down  in  the  center  while 
the  borders  extend.  Cavities  may  thus  be  formed,  simulating 
tuberculosis.  During  the  period  of  hardening  the  physical 
signs  resemble  pneumonia.  Secondary  pulmonary  carcinoma 
is  usually  multiple  and  very  small,  simulating  miliary  tuber- 
culosis. The  symptoms  are  not  clear  and  it  is  often  difficult  to 
say  whether  it  is  cancer,  local  tuberculosis,  pneumonia,  pleurisy, 
miliary  tuberculosis  or  bronchiectasis.  There  is  no  fever,  rarely 
pain,  but  occasionally  hemorrhage  or  a  hemorrhagic  expectora- 
tion, the  blood  being  intimately  mixed  with  mucus.  Dyspnea 
with  shallow  breathing  is  a  constant  symptom.  In  rare  cases 
the  tumor  will  cause  bulging  of  the  chest  wall,  or  displacement  of 
the  heart. 

Treatment  is  entirely  symptomatic.  Operative  procedures 
have  been  reported  but  none  have  ever  been  successful  in  the 
aged.  Arsenic  has  been  used  with  temporary  success  in  the 
cachexia  and  morphine  is  generally  the  only  means  of  relieving 
the  distressing  symptoms. 

Pleural  Cancer. — Cancer  growths  in  the  pleura  are  rare  and 
almost  always  secondary.  The  early  symptoms  are  those  of 
pleurisy,  later  pressure  symptoms  and  pain  occur.  The  cachexia 
is  marked,  as  the  disease  in  the  pleura  is  usually  a  late  affection. 
A  rare  form  of  primary  endothelial  cancer  called  lymphangitis 
carcinomatodes  is  peculiar  to  the  pleura.  Secondary  growths 
occur  in  the  lymph  channels  and  may  invade  the  lungs  and  bron- 
chi. The  early  symptoms  are  those  of  serofibrinous  pleurisy 
without  change  of  the  border  of  dulness  upon  change  of  position. 
Puncture  produces  a  serochylous  exudate  containing  epithe- 
lial debris  and  round,  generally  polynucleated  cells.  The 
needle  passes  through  denser  tissue  than  in  ordinary  pleurisy 
(Schwalbe).  The  growth  is  frequently  painful,  the  pain  ra- 
diating toward  the  arm.  The  pressure  upon  the  lung  will 
produce  dyspnea  and  if  erosion  of  blood-vessels  occurs  there  will 
be  a  hemorrhagic  expectoration.  This  form  of  malignant  growth 
progresses  more  slowly  than  other  forms  of  cancer,  the  cachexia 
18 


274  PATHOLOGICAL   OLD   AGE 

sets  in  late  and  the  fatal  issue  may  not  be  reached  until  several 
years  after  the  initial  symptoms.  There  is  no  curative  treat- 
ment for  pleural  cancer.  Aspiration  may  relieve  dyspnea  if 
there  is  much  exudate  and  narcotics  must  be  given  toward  the 
end  to  relieve  pain. 

Mediastinal  Cancer. — Cancer  in  the  mediastinum  is  often 
a  primary  lymphadenoma  of  the  mediastinal  lymphatics,  occa- 
sionally secondary  to  cancer  in  a  neighboring  tissue.  The 
symptoms  are  principally  due  to  pressure  upon  organs  or  to 
displacement  of  tissues  by  the  growth.  Pain  is  infrequent  but 
there  is  generally  tenderness  over  the  site  of  the  growth.  The 
diagnosis  must  be  often  made  by  the  pressure  symptoms  and  by 
exclusion.  Cachexia  sets  in  early  and  death  is  due  to  either 
exhaustion  or  asphyxia  from  pressure  upon  the  trachea  or  bron- 
chus.    The  treatment  is  surgical. 

Esophageal  Cancer. — Esophageal  cancer  is  usually  an  epi- 
thelioma, occurring  in  the  lower  third  of  the  tube.  In  the  aged 
the  growth  generally  proceeds  upward  and  into  the  cavity  of 
the  tube,  narrowing  and  finally  completely  occluding  the  caliber. 
The  symptoms  are  a  progressive  dysphagia  with  a  sensation 
that  the  food  is  stopped  at  a  certain  point  and  powerful  efforts 
at  deglutition  must  be  made  to  carry  it  past  the  obstruction. 
Another  symptom  is  the  cachexia.  The  growth  rarely  proceeds 
outward  and  therefore  symptoms  of  pressure  upon  other  tissues 
are  rare.  There  is  occasional  pain,  never  severe,  at  the  point  of 
obstruction.  Food  when  regurgitated  is  covered  with  mucus, 
sometimes  with  blood.  The  neighboring  lymphatics  are  some- 
times involved  but  death  from  asthenia  generally  sets  in  before 
secondary  cancers  appear.  Esophageal  sounds  may  be  used  to 
determine  the  location  of  the  obstruction,  but  any  effort  to  force 
the  sound  past  that  point  may  cause  inflammation  or  perforation 
and  collapse.  Perforation  through  the  cancer  growth  is  rare 
however.  The  only  treatment  is  early  operation.  In  the  mean- 
time foods  must  be  given  in  liquid  form  until  complete  stenosis 
has  occurred  after  which  rectal  feeding  must  be  resorted  to. 
Narcotics  and  cocaine  are  only  of  temporary  benefit  to  relieve 
pain  but  the  pain  in  the  aged  is  seldom  severe  enough  to  require 
treatment. 


GASTRIC   CARCINOMA  275 

Gastric  Carcinoma 

Gastric  carcinoma  is  the  most  frequent  of  the  visceral 
cancers  occurring  in  the  aged.  It  is  usually  a  cylinder-celled 
epithelioma.  The  soft  encephaloid  and  the  hard  scirrhus 
cancers  are  occasionally  found,  but  the  colloid  form  is  rare. 
Writers  generally  agree  that  the  pylorus  is  the  favored  site  of 
gastric  cancer,  but  there  is  considerable  difference  of  opinion  as 
to  the  main  etiological  factor.  Wilson  and  McCarty  of  the 
Mayo  clinic  found  that  7 1  per  cent,  had  developed  on  the  base  of 
an  old  ulcer;  French  says  a  history  of  ulcer  or  injury  is  obtained 
in  6  per  cent,  but  fully  half  of  the  cases  operated  upon  show 
evidences  of  previous  ulcer;  while  Weinstein  agrees  that  some 
cancers  do  develop  from  ulcers,  but  he  rejects  the  high  percentage 
given  by  Wilson  and  McCarty.  Ewald  points  out  the  rarity  of 
gastric  ulcer  in  the  aged  and  sees  in  traumatism  affecting  the  walls 
of  the  stomach  a  notable  etiological  factor.  To  harmonize 
these  diverse  views  with  the  prevalence  of  cancer  at  the  pylorus 
we  must  believe  that  most  gastric  cancers  in  the  aged  result 
from  the  scar  of  an  early  latent  ulcer.  Gastric  carcinoma  is 
generally  a  primary  cancer  and  is  followed  by  involvement  of  the 
lymphatic  glands,  often  by  growths  in  the  liver  or  gall-bladder, 
occasionally  in  the  peritoneum,  intestines  or  other  tissues. 
These  secondary  cancers  may  produce  more  disturbance  than 
the  primary  lesion. 

Symptoms. — There  are  no  early  pathognomonic  symptoms 
of  the  disease.  The  rarity  of  ulcer  in  the  aged  disposes  of  this 
precancerous  stage,  but  when  an  ulcer  exists  sudden  or  rapid 
diminution  of  free  hydrochloric  acid  and  the  presence  of  lactic 
acid,  in  conjunction  with  other  symptoms,  points  strongly  to 
cancer  and  is  nearly  pathognomonic.  Weinstein  says  a  sudden 
abrupt  onset  in  a  person  who  had  been  in  perfect  health  is  one  of 
the  strongest  links  in  the  cancer  chain,  while  Cabot  declares  that 
any  type  of  dyspepsia  occurring  in  a  person  over  forty  who  had 
had  no  such  trouble  before,  is  strongly  suggestive  of  cancer. 
These  statements  do  not  hold  good  in  senile  cases,  for  in  most 
cases  there  is  a  history  of  gastric  disturbance  going  back  per- 
haps for  months  before  there  are  any  other  symptoms  of  cancer, 
and  gastric  disturbances  of  the  aged  are  rather  frequent,  yet  few 
develop  into  cancer. 


276  PATHOLOGICAL   OLD   AGE 

The  early  symptoms  depend  mainly  upon  the  location  of  the 
growth.  There  is  generally  loss  of  appetite  and  a  rapidly  devel- 
oping cachexia.  If  the  cancer  is  situated  at  the  fundus,  pain, 
nausea  and  vomiting  occur  late  and  the  disease  progresses  more 
slowly  than  when  it  is  situated  at  the  pylorus.  The  cachexia 
is  associated  with  a  pronounced  anemia,  the  red  cells  may  sink 
to  3,000,000  or  less  while  the  hemoglobin  may  drop  to  50  per 
cent,  or  less.  Emaciation  sets  in  early.  It  proceeds  rapidly  if 
the  cancer  is  at  the  pylorus  where  it  interferes  with  the  passage 
of  food  into  the  duodenum  or  if  situated  at  the  cardiac  orifice 
where  it  interferes  with  the  passage  of  food  into  the  stomach.  If 
either  orifice  is  completely  occluded  death  from  starvation 
soon  follows.  The  skin  in  cancer  cachexia  presents  a  muddy, 
sallow  or  ocherous  hue  most  pronounced  on  exposed  surfaces,  and 
it  is  usually  dry  and  wrinkled.  The  secondary  group  of  symp- 
toms— pain,  nausea,  vomiting — may  vary  in  degree  or  be  absent 
altogether.  Pain  usually  comes  on  soon  after  the  ingestion  of 
food,  but  it  may  occur  paroxysmally  at  any  time.  It  is  an  early 
symptom  in  cases  where  a  cancer  develops  upon  an  existing 
ulcer  and  a  late  one  if  the  cancer  is  at  the  fundus.  The  degree 
of  pain  varies.  Nausea  and  vomiting  are  usually  early  symp- 
toms although  in  the  aged  vomiting  is  infrequent  and  requires 
severe  straining.  The  vomited  matter  consists  of  food  in  various 
stages  of  digestion,  mixed  with  mucus  and  sometimes  blood. 
Food  vomited  two  or  three  hours  after  a  meal  is  usually  foul  or 
sour  smelling.  Blood  is  generally  present  early  but  in  quantities 
so  small  that  a  microscopic  or  chemical  examination  may  be 
required  to  determine  its  presence.  The  ' '  coffee  ground ' '  vomit, 
which  contains  digested  blood  with  the  hemoglobin  converted 
into  hematin,  is  a  late  but  almost  pathognomonic  sign  of  cancer. 
Lactic  acid  bacilli  are  generally  found  in  the  vomited  matter. 
Of  the  physical  signs  the  most  important  is  the  presence  of  a 
growth,  usually  at  the  pylorus,  firm,  smooth  or  nodular,  and 
generally  movable.  It  rises  and  falls  with  respiration  and  in 
the  aged,  who  generally  have  wasted  abdominal  muscles,  it 
can  be  grasped  during  expiration.  A  growth  at  the  fundus, 
usually  found  at  the  lesser  curvature  is  not  palpable.  The 
involvement  of  the  lymphatics  confirms  the  diagnosis  of  cancer 
in  doubtful  cases.  While  there  is  not  a  single  pathognomonic 
sign  of  early  gastric  cancer  (except  the  very  rare  occurrence  of 


INTESTINAL   CANCER  277 

cancer  cells  in  the  vomitus)  and  each  individual  sign  and  symp- 
tom may  be  found  in  some  other  condition,  there  are  almost 
invariably  several  symptoms  which  taken  collectively  are  con- 
clusive of  cancer  or  serve  to  exclude  other  conditions.  The 
diseases  which  might  be  mistaken  for  gastric  cancer  are  ulcer, 
chronic  gastritis,  benign  growths,  cancers  outside  of  the 
stomach,  and  pylorospasm.  The  discovery  of  dissolved  albu- 
min in  the  stomach  contents  an  hour  after  taking  the  Ewald 
test  meal  is  pathognomonic  of  advanced  gastric  cancer. 
Benign  growths  in  the  stomach  are  very  rare,  and  the  tumor 
of  pylorospasm  will  usually  disappear.  Ulcer  and  gastritis 
can  be  excluded  by  the  history  and  the  examination  of  the 
stomach  contents. 

Treatment. — The  certainty  of  a  fatal  issue  without  operation 
and  the  possibility  of  a  cure  or  at  least  the  prolongation  of  life 
by  operation  justifies  operative  procedure  in  every  case,  however 
hopeless  the  outlook  may  be.  Drugs,  except  for  the  relief  of 
distressing  symptoms,  are  useless.  In  senile  cases  especially, 
early  operation  is  imperative  and  drug  treatment  may  not  even 
relieve  symptoms  unless  given  in  toxic  doses.  The  only  indi- 
cations for  drug  treatment  are  to  relieve  the  pain,  nausea  and 
vomiting,  while  awaiting  the  operation.  The  most  effectual 
drug  for  these  symptoms  is  cocaine  in  i/8-grain  doses.  Mor- 
phine and  other  opiates  still  further  diminish  the  motility  of 
the  organ,  prevent  peristalsis  and  weaken  the  respiratory  cen- 
ters. Theoretically  food  given  with  acidulated  pepsin  and 
predigested  foods  ought  to  be  beneficial;  usually,  however,  they 
are  of  small  service,  as  little  is  absorbed  from  the  stomach,  and 
where  a  pyloric  stenosis  exists  little  if  any  finds  its  way  into  the 
duodenum.  The  main  advantage  derived  from  these  foods  is 
less  likelihood  of  fermentation.  If  the  vomited  matter  smells 
sour  resorcin,  salol  or  the  sulphocarbolates  can  be  given.  Hemo- 
globin, manganese  and  arsenic  may  be  administered  to  improve 
the  anemia,  although  they  are  rarely  of  much  service.  If  the 
cancer  is  at  the  cardiac  orifice  drugs  and  food  must  be  given  in 
liquid  form.  Rectal  alimentation  is  of  service  for  a  few  days, 
but  it  is  impossible  to  introduce  sufficient  food  that  way  to 
completely  nourish  an  individual. 

Intestinal    Cancer. — Nearly    two-thirds    of    all    intestinal 
cancers  occur  in  the  rectum.     Sutton  says  that  75  per  cent. 


278  PATHOLOGICAL   OLD   AGE 

occur  in  the  rectum  and  25  per  cent,  occur  in  other  parts  of  the 
large  intestines.  Rectal  cancers  are,  as  a  rule,  mild  in  their 
symptoms,  progress  slowly  and  cause  comparatively  little  dis- 
turbance until  far  advanced.  Secondary  cancers  occur  late  and 
the  cachexia  is  rarely  as  pronounced  as  in  cancers  elsewhere.  In 
many  cases  the  symptoms  of  pressure  upon  adjoining  tissues  are 
more  marked  than  the  other  symptoms  and  signs  of  a  growth. 
Pressure  upon  a  nerve  or  plexus  will  produce  neuralgic  pains, 
while  pressure  upon  a  vein  will  cause  varix  or  edema.  There 
are  no  pathognomonic  symptoms  of  a  non-palpable  cancer.  A 
cancer  in  the  sigmoid  or  rectum  can  usually  be  seen  through  a 
colonoscope  and  a  rectal  cancer  can  usually  be  felt,  by  digital 
examination,  as  a  hard,  ulcerating  mass.  Growths  in  other 
parts  of  the  intestines  can  sometimes  be  felt  through  the  flaccid 
walls  but  it  is  necessary  to  eliminate  first  tumors  of  the  liver, 
kidney,  stomach  and  spleen. 

The  early  symptoms  of  intestinal  cancer  are  irregular  stools, 
sometimes  constipation,  at  other  times  diarrhea,  sometimes 
hard,  at  other  times  soft  or  watery  stools,  sometimes  copious 
then  again  scanty,  and  almost  always  containing  traces  of  blood. 
Mummery  says  small  frequent  urgent  stools  indicate  rectal 
cancer.  If  the  cancer  is  above  the  cecum  the  blood  is  mixed  with 
the  stool,  if  below  the  cecum  it  covers  the  stool.  There  is  flatu- 
lence and  borborygmus,  sometimes  colicky  pain  but  more  often 
an  ache  in  the  region  of  the  lesion  with  a  painful  spot  over  the 
growth.  The  diagnosis,  however,  is  never  assured  until  the 
growth  is  palpable.  Other  diseases  liable  to  be  mistaken  for 
intestinal  cancer  in  which  no  tumor  can  be  felt  are  chronic 
ulcerative  enteritis,  syphilis,  tuberculosis,  concretions  and  ac- 
tinomycosis. The  last  one  is  very  rare,  while  syphilis  and 
tuberculosis  can  be  determined  by  serum  tests.  Concretions  will 
disappear  under  a  brisk  cathartic  and  chronic  ulcerative  enter- 
itis has  diarrhea  with  pus  and  shreds  of  mucus  in  the  feces. 
As  the  cancer  increases  it  diminishes  the  caliber  of  the  bowel  and 
finally  causes  complete  stenosis  with  the  symptom  of  intestinal 
occlusion.  The  treatment  is  surgical.  In  no  other  form  of 
cancer  is  the  surgical  prognosis  as  favorable  as  in  rectal  cancer. 
Without  operation  the  prognosis  is  fatal.  The  only  drug  indi- 
cations are  for  the  relief  of  pain  and  constipation.     If  the  opera- 


CANCER   OF   LIVER  279 

tion  is  delayed  until  secondary  cancers  form  or  until  complete 
occlusion  has  occurred,  recovery  is  doubtful. 

Cancer  of  Liver. — Hepatic  cancer  is  almost  always  secondary 
to  gastric  cancer,  cancer  in  other  parts  of  the  digestive  tract,  or 
cancer  of  the  female  genitals,  and  occasionally  to  cancers  of 
some  other  part  of  the  body.  Less  than  5  per  cent,  are  primary. 
A  fairly  pathognomonic  symptom-complex  is  enlargement  and 
tumefaction  of  the  organ,  presence  of  a  tumor  which  is  painful 
on  pressure,  colicky  pains  about  the  organ,  radiating  toward 
the  right  axilla,  and  the  general  cachexia  with  pronounced  jaun- 
dice. In  some  cases  nodules  can  be  felt  at  the  edge  or  upon  the 
surface  of  the  liver.  The  jaundice  is  of  hepatogenous  origin, 
noticeable  on  the  conjunctiva  and  increasing  as  the  growth 
interferes  more  and  more  with  the  secretion  of  bile.  Owing  to 
bile  retention  and  interference  with  its  passage  to  the  gall- 
bladder and  intestines,  another  set  of  symptoms  is  produced. 
These  are,  anorexia,  especially  a  distaste  for  meat  and  fat; 
flatulence,  meteorism,  clayey,  foul-smelling  stools,  dark  brown 
urine  containing  bile  pigment,  intense  pruritus,  and,  usually, 
nervous  and  cerebral  symptoms.  In  some  cases  rapid  emacia- 
tion with  jaundice  and  a  dull  ache  on  pressure  are  the  only 
suggestive  symptoms.  Primary  cancer  does  not  always  give 
these  symptoms.  In  cases  in  which  the  carcinoma  is  in  the  sub- 
stance of  the  liver  and  does  not  reach  the  surface,  the  organ  will 
be  increased  in  size  but  no  nodules  will  be  felt  and  icterus  may 
be  slight  or  even  absent  if  the  growth  does  not  obstruct  the  free 
flow  of  bile.  While  there  is  no  single  pathognomonic  sign,  yet 
the  history  of  a  primary  cancer,  the  rapid  emaciation,  jaundice, 
pain  and  increased  size  of  the  organ  will  suffice  to  exclude  most 
other  diseases.  Cirrhosis  and  syphilis  are  infrequent  in  the 
aged.  It  is  sometimes  difficult  to  differentiate  between  a  cancer 
of  the  liver  and  that  of  an  adjoining  organ  in  the  aged,  as  the 
liver  then  usually  lies  lower  in  the  abdominal  cavity  than  in 
maturity  and  growths  in  adjoining  organs  may  become  adherent 
to  the  liver.  It  is,  however,  only  in  the  cases  where  the  primary 
disease  is  so  mild  that  it  is  overlooked  that  a  mistake  can  be 
made.  Cachexia  is  common  to  all  types.  Cachexia  without 
marked  jaundice  points  to  cancer  in  some  other  organ  than  the 
liver,  i.e.,  gall-bladder,  or  ducts,  or  pancreas.  It  is  impossible 
to  differentiate  between  cancer  of  the  liver  and  that  of  the  gall- 


28o  PATHOLOGICAL   OLD   AGE 

bladder  unless  there  is  a  palpable  tumor  which  can  be  denned. 
In  cancer  of  the  pancreas  the  pain  is  to  the  left  of  the  median  line, 
there  is  often  occlusion  of  the  pylorus  with  dilatation  of  the  stom- 
ach and  if  the  tumor  is  palpable  it  will  be  found  that  it  does  not 
move  with  respiration.     Glycosuria  may  also  be  present. 

There  is  no  known  cure  for  cancer  of  the  liver  and  death 
generally  occurs  within  a  few  months  after  its  symptoms  appear. 
If  secondary  to  another  cancer,  operation  can  serve  no  purpose 
whatever.  In  the  rare  cases  of  primary  cancer  of  the  liver, 
benefit  from  an  operation  is  possible  although  such  operations 
are  almost  invariably  fatal.  All  that  can  be  done  is  to  tempo- 
rarily relieve  distressing  symptoms  by  narcotics,  analgesics, 
hypnotics,  etc. 

Cancer  of  the  Gall-badder. — With  the  exception  of  the 
location  of  the  growth,  the  symptoms  of  cancer  of  the  gall- 
bladder are  the  same  as  those  of  cancer  of  the  liver.  A  palpable 
enlargement  of  the  gall-bladder,  because  of  its  position  under  the 
liver,  appears  as  an  enlargement  of  or  growth  upon  the  liver 
itself.  The  disease  is  almost  always  secondary  and  what  has 
been  said  of  the  prognosis  and  treatment  of  cancer  of  the  liver 
applies  to  this  condition.  Gall-stones  may  give  similar  symp- 
toms but  the  history,  paroxysmal  colic,  possible  finding  of 
stones  in  the  stools  on  the  one  hand,  and  the  history  of  a  primary 
cancer  or  lymphatic  involvement  and  rapidly  progressive  ca- 
chexia, will  suffice  to  differentiate  between  them. 

Cancer  of  the  gall-ducts  cannot  be  differentiated  from  he- 
patic or  biliary  cancer. 

Cancer  of  the  Pancreas. — Cancer  of  the  pancreas  is  rare, 
but  most  cases  occur  in  advanced  age.     The  clinical  picture 
described  by  Bard   and  Pic   includes  icterus,  progressive  and 
without  remissions,   enormous  distention  of  the  gall-bladder, 
readily  perceived  upon  palpation,  no  increase  in  the  size  of  the 
liver,  temperature  habitually  subnormal,  rapid  emaciation  and 
cachexia,  short  duration  of  the  disease,  sometimes  a  tumor  in 
the   epigastrium,    absolute   decoloration   of   the  fecal   matter, 
abundant  biliary  pigment  in  the   urine  and  frequent  albumi- 
nuria.    In  the  absence  of  tumor  there  symptoms  apply  as  well 
to  cancer  of  the  gall-bladder.      DaCosta  found  a  tumor  in  13 
out   of  137  cases  of  cancer  of  the  pancreas.     More  frequent 
symptoms  are  pain  in  the  region  of  the  pancreas,  the  symptoms 


PROSTATIC   CANCER  28 1 

of  pyloric  or  duodenal  stenosis,  fatty  stools  and  glycosuria. 
While  the  diagnosis  of  a  cancer  is  not  difficult  in  the  presence 
of  rapidly  progressive  cachexia  and  pain,  in  the  absence  of  a 
tumor  it  is  often  impossible  to  determine  whether  the  cancer 
is  in  the  pancreas,  duodenum  or  gall-duct.  Cancer  in  the  body 
or  tail  of  the  pancreas  is  very  rare  and  when  it  occurs  it  does 
not  produce  jaundice,  as  the  growth  doer  not  compress  the 
bile-duct.  There  is,  however,  pain,  constant  or  paroxysmal, 
not  aggravated  by  food,  radiating  to  the  left  and  of  more  inten- 
sity than  in  any  other  abdominal  tumor.  Packard  points  out  an 
area  of  tenderness  above  and  to  the  left  of  the  umbilicus  indica- 
tive of  pancreatic  disease  and  this  with  the  cachexia  and  other 
symptoms  of  cancer  is  sufficiently  suggestive  to  make  a  fairly 
certain  diagnosis.  The  only  treatment  is  surgical.  Symp- 
tomatic remedies  may  be  employed  for  the  relief  of  pain  and  to 
supply  medicinally  the  deficient  pancreatic  juice  and  bile. 

Prostatic  Cancer. — Prostatic  cancer  is  one  of  the  more  fre- 
quent forms  of  cancer  in  the  aged.  It  is  usually  a  primary 
scirrhus,  occurring  either  as  a  cancer  growth  upon  an  enlarged 
prostate  or  as  a  hypertrophied  prostate  which  became  cancer- 
ous. Fuller  says  1/7  or  1/8  of  cases  coming  under  his  observa- 
tion with  symptoms  of  prostatic  obstruction  were  cancer. 
An  early  symptom  of  a  primary  cancer  is  an  increased  fre- 
quency of  urination  and  rapid  symptoms  of  obstruction  which 
may  appear  in  from  four  to  six  weeks,  later,  involvement  of 
adjoining  tissues  and  cachexia.  In  some  cases  there  are  no 
early  symptoms  except  those  of  hypertrophy,  which  may  exist 
for  years  before  the  obstruction  is  sufficiently  marked  to  give 
decided  symptoms  and  these  symptoms  proceed  slowly.  Hema- 
turia, the  blood  appearing  at  the  end  of  urination,  points  to 
cancer  or  acute  cystitis,  but  when  associated  with  prostatic 
obstruction  it  is  strongly  suggestive  of  cancer  of  the  prostate. 
Digital  rectal  examination  reveals  a  hypertrophied  prostate 
usually  nodular,  irregular,  hard  and  when  adjoining  tissues  are 
involved  it  is  immovable  or  there  is  a  sensation  under  the  finger 
as  if  adjoining  tissue  is  being  dragged  along.  Pain,  except  the 
dull  ache  that  accompanies  hypertrophy,  does  not  occur  until 
adjacent  tissues  are  involved  and  then  it  is  frequently  a  sharp 
pain  radiating  from  the  groin  down  the  thighs,  and  toward 
the  sacrum,  occasionally  to  the  suprapubic  region.     When  the 


282  PATHOLOGICAL   OLD   AGE 

active  symptoms,  frequent  urination,  rapidly  increasing  pros- 
tatic obstruction  with  hypertrophy,  blood  at  the  end  of  urin- 
ation, with  rapid  emaciation  and  other  concomitants  of  cachexia 
appear,  a  mistake  is  hardly  possible.  The  only  successful  treat- 
ment of  prostatic  cancer  is  early  extirpation  of  the  gland.  If 
the  disease  has  invaded  adjoining  tissues,  there  is  no  likelihood 
that  any  operation  can  radically  free  the  patient  of  his  trouble 
(Fuller).  The  increasing  obstruction  to  urination  will  sooner  or 
later  make  operative  interference  imperative.  Drug  treatment 
is  useless  except  for  the  relief  of  pain,  when  the  narcotics  may  be 
given. 

Cancer  of  the  Bladder. — Cancer  of  the  bladder  occurs  occa- 
sionally in  the  aged  male  and  less  frequently  in  the  aged  female. 
It  originates  usually  in  a  benign  papillary  fibroma  which  may 
have  existed  for  years.  Secondary  cancers  generally  follow 
uterine  cancer  in  the  female  and  cancer  of  the  rectum  or  prostate 
in  the  male.  There  are  no  pathognomonic  symptoms  of  cancer 
of  the  bladder  unless  particles  of  the  growth  are  found  in  the 
urine.  The  usual  symptoms,  pain,  hematuria  and  dysuria, 
may  occur  in  other  conditions,  notably  in  benign  tumors  and 
in  acute  cystitis,  while  the  symptoms  of  some  cases  of  cancer 
are  mild  and  intermittent.  If  above-mentioned  symptoms 
appear  in  the  course  of  a  cancer  of  the  rectum,  prostate  or  uterus 
it  is  strongly  suggestive  of  secondary  cancer  of  the  bladder.  A 
positive  diagnosis,  however,  requires  the  use  of  the  cystoscope 
or  the  frequent  examination  of  the  urine  for  cancer  cells.  The 
tumor  is  rarely  large  enough  or  located  so  favorably  that  it  can 
be  felt.     In  primary  cases  cachexia  appears  late. 

If  the  disease  is  primary  and  localized  surgical  measures  may 
effect  a  cure.  If  secondary  cancers  have  occurred,  operation  is 
useless  except  possibly  to  relieve  an  occlusion  of  the  sphincter. 
Bangs  reports  several  cases  of  inoperable  cancer  in  which  daily 
irrigation  of  the  bladder  with  a  hot  solution  (ioo°  raised  slowly 
to  1050  F.)  of  1/2  per  cent,  creolin  relieved  the  irritability, 
lessened  the  hemorrhage  and  diminished  the  size  of  the  growth. 
The  effect  was  not  permanent  but  relief  was  secured  for  several 
months. 

Cancer  of  the  Testicle. — Cancer  of  the  testicle  in  the  aged  is 
almost  always  secondary  to  cancer  of  the  prostate,  bladder  or 
rectum,  and  is  then  readily  diagnosed  by  its  rapid  increase  in 


CANCER   OF   THE   FEMALE    GENITALS  283 

size.  It  is  not  painful  except  on  pressure.  When  occurring  as 
a  secondary  cancer  the  neighboring  lymphatics  are  already  infil- 
trated and  operation  is  useless.  In  the  rare  cases  of  primary 
cancer  in  the  aged  the  disease  may  remain  quiescent  for  years, 
providing  the  testes  have  been  removed  early.  The  danger  of 
delay  lies  in  the  involvement  of  the  ileolumbar  lymphatics  and 
extension  through  them.  If  these  glands  have  not  been  affected 
complete  cure  is  possible. 

Cancer  of  the  Scrotum. — Cancer  of  the  scrotum  usually 
occurs  as  a  papillomatous  growth  on  the  site  of  a  scar,  wart  or 
eczema  and  follows  the  usual  course  of  skin  epithelioma.  The 
treatment  is  excision.  If  performed  before  the  lymphatics 
are  involved  complete  cure  is  possible. 

Cancer  of  the  Penis. — Cancer  of  the  penis  may  occur  as  a 
primary  or  secondary  disease.  The  usual  location  is  upon  the 
glans  where  it  begins  as  a  painless  wart  which  rapidly  increases, 
forming  a  cauliflower  excrescence.  It  rarely  invades  the  corpus 
cavernosa,  but  the  inguinal  and  retroperitoneal  glands  are 
involved  early.  In  those  cancers  which  involve  the  skin,  as 
in  cancer  of  the  penis  and  scrotum,  early  operation  generally 
affects  a  cure,  providing  the  neighboring  glands  are  not  in- 
volved, or  if  involved,  are  completely  removed.  Treatment 
with  the  X-ray,  radium,  etc.,  is  still  experimental  and  while 
justifiable  they  often  fail  and  valuable  time  is  lost  thereby. 

Cancer  of  the  Female  Genitals. — In  considering  cancers  in 
the  aged  we  must  include  cancers  of  the  female  genital  organs, 
although  these  belong  exclusively  in  the  domain  of  the  gynecolo- 
gist. The  most  frequent  of  these  is  cancer  of  the  uterus.  This 
generally  begins  as  a  primary  benign  neoplasm  which  becomes 
malignant.  A  provisional  diagnosis  can  usually  be  made  if, 
after  the  menopause,  a  hemorrhage  or  a  serosanguineous  dis- 
charge occurs,  or  if  a  persistent  watery  leucorrhea  becomes 
blood  tinged  or  assumes  a  fetid  odor.  Neuralgic  pains  occur 
if  a  nerve  is  pressed  upon;  usually,  however,  there  is  little  pain, 
but  a  constant  dull  ache  in  the  lumbar  region.  Violet  says  that 
an  early  diagnosis  can  usually  be  made  by  introducing  a  sound 
and  gently  moving  it  over  the  inner  surface  of  the  uterus.  If 
there  is  cancer  the  physician  can  feel  the  sound  scrape  over  the 
roughened  surface  of  the  growth.  To  make  the  diagnosis  abso- 
lute, curettement  and  microscopic  examination  of  the  scrapings 


284  PATHOLOGICAL   OLD    AGE 

are  necessary.  Cachexia  sets  in  early  but  is  not  well  marked 
until  the  disease  is  well  advanced.  Montgomery  points  out 
that,  where  there  is  a  history  of  previous  tubal  inflammation  a 
menorrhagia  and  watery  discharge  indicates  cancer  of  the  Fallo- 
pian tube.  Cervical  cancer  can  usually  be  seen  through  a 
speculum  and  is  easily  felt.  Moulton  says,  however,  that  when  a 
cervical  cancer  has  reached  the  stage  when  it  can  be  diagnosed 
unhesitatingly  by  the  touch,  eye,  or  history,  then  it  has  reached 
the  border  line  between  possibility  and  impossibility  of  cure. 
The  early  treatment  is  solely  surgical,  and  delay  occasioned  by 
the  use  of  medical  measures  simply  lessens  the  chances  of  suc- 
cessful operation.  Cancer  of  other  parts  of  the  female  genitals 
is  rare  in  the  aged.  When  one  occurs  it  is  usually  an  epithelioma 
following  a  surface  lesion  such  as  eczema,  excoriations  from  irri- 
tating discharges,  scars  of  chancres  or  chancroids,  etc.  The 
treatment  is  excision  of  the  mass  but  recurrence  either  on  the 
site  of  the  original  growth  or  in  the  neighboring  inguinal  glands 
is  of  frequent  occurrence. 

Cancer  of  the  Breast. — This  is  usually  a  primary  cancer, 
occurring  in  most  cases  soon  after  the  menopause.  According 
to  Isaacs  from  80  to  90  per  cent,  of  all  tumors  of  the  breast  are 
malignant  and  of  the  remainder  a  large  proportion  will  become 
malignant  if  permitted  to  progress.  The  early  symptoms  are 
the  presence  of  a  hard  mass,  pain  or  tenderness  and  diminished 
mobility  of  the  breast  with  elevation  of  the  nipple  of  the  affected 
side.  A  bloody  discharge  from  the  nipple  is  strongly  suggestive 
of  carcinoma.  Later  symptoms  are  retraction  of  the  nipple, 
adhesion  of  the  growth  to  the  chest  wall,  lymphatic  involve- 
ment, edema  of  the  arm,  ulceration,  and  cachexia.  The  treat- 
ment is  surgical ;  the  earlier  performed  the  better  the  prognosis. 
Abbe  succeeded  in  healing  an  ulcerating  inoperable  cancer  of 
the  breast  by  radium. 

GRAWITZ'S  CACHEXIA 

Etiology. — This  disease,  described  by  Grawitz  as  a  "fatal 
cachexia  without  discernible  anatomical  cause,"  somewhat 
resembles  pernicious  anemia,  but  the  red  blood  cells  show  no 
degenerative  change,  though  they  may  be  diminished  in  number. 
No  change  in  any  organ  or  tissue  has  been  found  to  explain  the 
rapid  anemia,  emaciation,  loss  of  strength  and  general  physical 


CHRONIC   LARYNGITIS  285 

breakdown,  and  it  is  assumed  that  the  disease  is  due  to  some 
deleterious  substance  which  has  gained  access  to  the  blood; 
possibly  the  chromaffine  substance  of  the  adrenals. 

Symptoms. — The  symptoms  are  rapidly  increasing  pallor, 
emaciation,  loss  of  strength,  and  a  mental  and  physical  depres- 
sion, leading  to  fatal  exhaustion. 

The  differential  diagnosis  between  this  disease  and  perni- 
cious anemia  rests  upon  the  examination  of  the  blood.  The  red 
cells  number  from  1,000,000  to  3,000,000  and  they  show  no 
degenerative  change.  The  disease  resembles  the  cancer  ca- 
chexia and  can  be  distinguished  from  cancer  only  by  the  local 
and  secondary  symptoms  of  the  latter  disease. 

Treatment. — There  is  no  known  remedy.  It  is  usually 
treated  as  pernicious  anemia,  and  is  always  fatal. 

CHRONIC   LARYNGITIS 

Chronic  Laryngitis  occurs  either  as  a  localized  disease  or  a 
part  of  a  more  extensive  chronic  inflammation  of  the  nares, 
pharynx,  bronchi,  etc.  It  appears  in  two  forms,  a  hyper- 
trophic catarrh  corresponding  to  chronic  hypertrophic  bron- 
chitis, and  an  atrophic  catarrh  corresponding  to  the  senile 
atrophic  bronchitis. 

Etiology. — The  hypertrophic  form  of  chronic  laryngitis 
occurs  most  frequently  in  speakers,  singers,  and  others  who  use 
the  voice  excessively,  or  in  those  who  have  had  repeated  attacks 
of  acute  laryngitis,  or  from  extension  of  a  chronic  catarrh  into 
adjoining  tissues  and  lastly  after  infectious  diseases  in  which 
the  mucous  membranes  are  profoundly  involved,  as  in  influenza 
and  tuberculosis.  The  atrophic  form  occurs  from  the  same 
causes  that  produce  senile  atrophic  bronchitis.  This  form  of 
laryngitis  is  a  true  senile  disease,  depending  upon  the  presence 
of  an  atrophied  mucous  membrane  which  had  been  irritated. 

Symptoms. — In  the  hypertrophic  form  there  is  hoarseness, 
especially  in  the  morning  until  the  secretion  which  has  collected 
during  the  night  has  been  expelled.  Involvement  of  adjacent 
tissues,  as  thickening  or  paresis  of  the  vocal  cords,  may  cause 
complete  aphonia.  There  is  a  persistent  feeling  of  tickling  or 
irritation,  rarely  pain,  a  desire  to  cough  but  no  relief  after 
coughing,  occasional  dysphagia  and  dyspnea.  In  the  atrophic 
form  the  voice  is  squeaky  and  weak  but  there  is  no  hoarseness 


286  PATHOLOGICAL    OLD   AGE 

or  aphonia,  the  throat  feels  dry  but  there  are  occasional  spas- 
modic attacks  of  coughing  with  expectoration  of  a  tenacious 
gray  mucus.  If  the  mucus  accumulates  upon  the  cords  or 
controlling  muscles  there  will  be  hoarseness,  perhaps  aphonia, 
but  with  the  removal  of  the  secretion  the  voice  is  again  thin  and 
squeaky.  The  diagnosis  can  readily  be  established  by  the 
laryngoscope.  The  grave  forms  of  laryngitis  associated  with 
tuberculosis,  cancer  or  syphilis  can  generally  be  differentiated 
by  the  history  and  accompanying  symptoms  of  the  primary 
disease. 

Treatment. — In  the  atrophic  form  of  chronic  laryngitis  local 
stimulation  is  required  and  can  best  be  accomplished  by  the 
inhalation  of  hot  water  to  which  menthol  and  eucalyptol  have 
been  added.  If  the  expectoration  is  purulent,  oil  of  turpentine 
inhalations  should  be  used  instead.  If  the  mucus  is  thick  and 
scanty  the  syrup  of  the  hypophosphite  of  ammonium  should  be 
given  in  dram  doses  several  times  a  day.  In  the  hypertrophic 
form  local  application  of  mild  astringents  is  indicated,  such  as 
blowing  dry  astringent  powders  or  brushing  the  inflamed  area 
with  a  weak  solution  of  iodine  or  nitrate  of  silver. 
Hygienic  measures  and  prophylaxis  are  self-evident. 

CHRONIC  HYPERTROPHIC  BRONCHIAL   CATARRH 

This  is  the  old  man's  winter  cough,  the  most  frequent 
bronchial  affection  of  the  aged,  and  bronchiectasis  is  almost  al- 
ways associated  with  it. 

Etiology. — This  form  of  bronchitis  comes  on  with  the  advent 
of  cold  weather  and  is  due  to  the  alternate  chilling  and  warming 
of  the  bronchial  mucous  membrane,  from  the  difference  in 
temperature  between  the  inspired  and  expired  air.  It  does  not 
appear  when  the  patient  spends  the  winter  in  a  warm  equable 
climate.  The  disease  occurs  most  frequently  among  those  who 
have  been  exposed  for  years  to  such  deleterious  influences  as 
dust,  vapors,  rapid  temperature  changes,  etc.,  and,  in  almost 
every  case,  a  tendency  to  catarrhal  affections,  carried  over  from 
earlier  life,  can  be  established.  It  is  occasionally  found  in 
cases  where  excessive  cautiousness  against  temperature  changes 
and  other  causes  of  bronchitis  has  produced  a  condition  of 
great  sensitiveness  in  the  bronchial  mucous  membrane.     In 


c * 


D- 


Lung,  Emphysema  and  Bronchiectasis.  (Natural  size.) 
(From  Coplin's  "Manual  of  Pathology.)  A.  Emphysema, 
vesicle.  B.  Enlarged  peribronchial  gland.  C.  Enlarged 
peribronchial  gland,  pigmented.     D,  D,  D.  Dilated  bronchi. 


CHRONIC  HYPERTROPHIC  BRONCHIAL   CATARRH  287 

such,  a  slight  indiscretion  as  a  draught,  or  a  momentary  chilling 
of  the  surface,  produces  a  bronchitis. 

Pathology. — There  is  a  passive  hyperemia  with  thickening  of 
the  mucous  membrane  and  enlargement  of  the  mucous  glands. 
The  latter  are  usually  open  and  are  surrounded  by  dark-colored 
zones.  The  blood-vessels  are  filled  and  tortuous.  Numerous 
small  elevations  and  depressions  are  found  in  the  mucous  walls 
and  the  tissue  feels  soft  and  velvety.  Later  on,  if  there  have 
been  violent  fits  of  coughing  weak  spots  in  the  bronchial  walls 
will  result  which  dilate,  producing  bronchiectasis.  These  dilata- 
tions form  sacs  and  pouches  and  may  become  cystic  reservoirs 
of  mucus  or  of  muco-purulent  matter.  In  some  cases  there  are 
alternating  areas  of  dilatation  and  stenosis,  the  latter  caused  by 
hypertrophy  of  the  mucous  membrane  or  by  hyperplasia  of 
fibrous  connective  tissue.  The  mucous  membrane  of  these 
dilatations  is  sometimes  atrophied  and  leathery  and  under 
severe  strain  of  coughing  it  may  rupture  permitting  the  contents 
to  enter  the  lung  tissue. 

Symptoms. — Chronic  hypertrophic  bronchial  catarrh  begins 
with  a  slight  cough  which  gives  little  distress  and  is  followed 
two  or  three  days  later  by  an  abundant  expectoration.  The 
expectoration  is  muco-purulent,  thick,  yellow,  sometimes  tinged 
with  green.  A  brownish  expectoration,  if  specially  abundant 
in  the  morning  and  associated  with  a  spasmodic  cough,  indicates 
bronchiectasis.  In  some  cases  of  chronic  hypertrophic  bron- 
chitis the  expectoration  becomes  purulent,  thin  and  grayish, 
or  heavy  and  greenish,  and  has  a  fetid  odor.  This  may  come 
from  abscess  or  gangrene  of  the  lung,  tuberculosis,  or  long 
retention  in  a  bronchiectatic  reservoir  where  the  mucus  became 
purulent.  In  the  last  case  there  are  no  severe  constitutional 
symptoms,  but  if  due  to  abscess  or  gangrene  there  are  symptoms 
of  septic  infection.  The  physical  signs  are  as  in  simple  bron- 
chitis. Large  dilatations  gave  amphoric  breathing,  cavernous 
resonance,  possibly  pectoriloquy  and  large  bubbling  rales.  The 
physical  signs  of  bronchiectasis  are  not  clear  but  the  diagnosis 
can  usually  be  made  by  the  large  amount  of  secretion  brought 
up  in  the  morning  with  a  spasmodic  cough  while,  if  there  is  no 
complicating  bronchiectasis,  the  amount  brought  up  in  the 
morning  exceeds  but  by  little  the  amount  expectorated  at  other 
times   of   the   day.     The   symptoms   of   bronchiectasis  persist 


288  PATHOLOGICAL   OLD   AGE 

during  the  whole  year  while  the  symptoms  of  hypertrophic 
bronchitis  disappear  with  the  advent  of  warm  weather  to  reap- 
pear at  the  next  approach  of  winter. 

Treatment. — The  successful  treatment  of  chronic  hyper- 
trophic bronchial  catarrh  depends  upon  the  ability  of  the  pa- 
tient to  go  to  a  warm  equable  dry  climate,  but  not  at  a  high 
elevation,  and  remain  there  all  winter.  The  disease  will  prob- 
ably not  appear  while  he  is  there  but  if  he  returns  to  a  cold 
climate,  the  disease  will  return  also.  As  long  as  he  is  obliged 
to  breathe  cold  air  he  will  suffer,  and  medicinal  treatment  is 
only  palliative  as  long  as  the  causative  factor  remains.  Little 
can  be  done  by  internal  medication,  but  the  inhalation  of  creo- 
sote, terebene  or  eucalyptol  is  sometimes  of  service.  Expec- 
torants useful  in  acute  bronchitis  are  generally  contraindicated 
in  this  disease.  The  occasional  administration  of  i/ioo  grain 
of  atropine  may  diminish  the  secretion  and  if  the  secretion  is 
tenaceous  the  muriate  of  ammonia  with  syrup  of  senega  may 
be  given.  If  there  is  a  putrid  bronchitis  a  2  per  cent,  spray  or 
inhalation  of  phenol  may  be  used  to  destroy  the  fetor  but  the 
treatment  must  be  directed  to  the  causative  condition.  Hy- 
gienic measures,  such  as  warm  clothing,  freedom  from  draughts, 
feet  protected  from  dampness,  etc.,  are  necessary  adjuncts  to 
the  treatment. 

PULMONARY  EDEMA 

Pulmonary  edema  occurs  frequently  in  the  aged  as  a  sec- 
ondary terminal  disease,  appearing  in  some  cases  during  the 
death  struggle.  More  often  it  initiates  the  series  of  phenomena 
that  are  associated  with  the  process  of  dissolution.  There  is  a 
transudation  of  serum  from  the  blood-vessels  into  the  intersti- 
tial tissue  and  air  vesicles,  blocking  the  latter  and  preventing 
aeration  of  blood.  A  recurrent  type  has  been  described  but 
in  the  aged  the  first  attack  is  almost  always  fatal. 

Etiology. — In  most  cases,  in  the  aged,  it  follows  a  passive 
hyperemia,  either  a  hypostatic  congestion  due  to  long  confine- 
ment to  one  position,  or  an  obstruction  to  the  return  circulation 
due  to  cardiac  or  pericardial  disease.  In  these  cases  separation 
of  the  serum  occurs  during  stasis  and  it  passes  out  of  the  vessels. 
Pulmonary  edema  also  occurs  in  hydremic  conditions  as  in 


PULMONARY   EDEMA  289 

nephritis,  cirrhosis  of  the  liver,  anemia,  scurvy,  etc.,  in  which 
diseases  there  is  a  tendency  of  the  serum  to  ooze  out  through 
the  vessels.  In  some  inflammatory  conditions,  as  in  pneumonia, 
bronchiolitis,  etc.,  there  may  be  stasis  with  separation  of  the 
serum  from  the  blood.  In  extreme  debility  with  weakened 
circulation,  and  in  many  fatal  diseases,  there  is,  toward  the  end, 
a  relaxation  of  the  blood-vessels  which  permits  the  exudation 
of  serum  and  its  transudation  into  the  surrounding  tissues  and 
into  the  air  vesicles. 

Pathology. — The  affected  portion  of  the  lung  becomes 
lighter  in  color  and  heavier  in  weight,  it  pits  upon  pressure  and 
upon  opening  the  chest  the  lung  does  not  collapse.  Serum  is 
found  in  the  alveoli  and  interstitial  tissue  and  if  there  has  been 
a  pulmonary  congestion  the  serum  is  blood  streaked.  On 
sectioning,  the  serum  exudes. 

Symptoms. — The  first  symptom  of  pulmonary  edema  is 
usually  a  sudden,  severe,  or  a  rapidly  increasing,  dyspnea  which 
is  soon  followed  by  an  abundant,  frothy  mucus  which  may  be 
blood  streaked.  The  respiration  is  increased  in  frequency  and 
the  patient  makes  violent  efforts  to  get  air,  sitting  up  and  bring- 
ing into  play  all  the  respiratory  muscles.  There  is  inspiratory 
and  expiratory  dyspnea,  the  expiration  being  accompanied  by 
an  audible  rattle  as  the  air  bubbles  up  through  the  tubes  that 
are  occluded  by  serum.  Cyanosis  often  occurs  toward  the  end. 
Some  cases  die  of  asphyxiation  with  the  symptoms  of  choking, 
in  others  there  is  coma.  The  physical  signs  are  dulness  over  the 
site  of  the  edema,  bubbling  rales  heard  with  inspiration  and  at 
the  beginning  of  expiration,  feeble  respiratory  murmur.  The 
sudden  or  rapid  onset  and  the  history  of  an  antecedent  causa- 
tive disease  distinguish  it  from  other  pulmonary  diseases. 

Prognosis. — Pulmonary  edema  in  the  aged  is  almost  invari- 
ably fatal,  death  usually  occurring  in  from  one  to  twenty-four 
hours  after  the  onset  of  the  disease.  It  occasionally  makes  its 
appearance  during  the  last  few  minutes  before  death. 

Treatment. — In  a  disease  which  is  almost  always  rapidly  fatal 
we  are  justified  in  employing  any  measures  which  might  pro- 
long life.  The  usual  remedies,  wet  or  dry  cups,  hot  fomenta- 
tions, mustard  and  turpentine  applications,  are  useless  in  the 
aged.  The  time  for  their  use  was  during  the  passive  hyperemia 
when  they  might  have  equalized  the  circulation  by  producing 
19 


29O  PATHOLOGICAL    OLD   AGE 

a  superficial  hyperemia,  but  after  transudation  of  serum  has 
taken  place  they  cannot  stimulate  absorption.  In  hydremic 
states  the  theoretical  treatment  is  to  secure  rapid  elimination  of 
fluid  by  means  of  hydragogue  cathartics,  diuretics  and  dia- 
phoretics. Such  rapid  elimination,  however  active,  weakens 
the  heart  and  does  not  remove  the  serum  from  the  air  vesicles. 
Venesection  will  either  immediately  destroy  the  patient  or  will 
afford  but  temporary  relief  by  relieving  the  local  congestion.  In 
such  cases  there  may  be  a  temporary  absorption  of  the  transu- 
date, but  the  vessels  soon  fill  again  and  the  serum  will  again 
transude  into  the  vesicles.  The  report  that  a  case  was  re- 
lieved by  turning  the  patient  on  his  stomach,  placing  him  across 
the  bed  and  supporting  his  abdomen  with  a  high  bolster,  while 
his  head  was  hanging  over  the  edge,  thereby  allowing  the  serum 
to  flow  out  by  gravity,  induced  the  author  to  try  this  in  one  case. 
The  patient  suffocated.  Oxygen  inhalation  will  relieve  the 
cyanosis  for  a  time,  but  as  the  disease  progresses  and  greater 
areas  of  lung  tissue  are  involved,  the  blood  becomes  more  con- 
taminated, finally  the  oxygen  cannot  aerate  the  blood  suffi- 
ciently and  coma  and  death  ensue. 

Suprarenal  preparations  will  sometimes  control  and  pre- 
vent further  transudation  if  given  at  the  onset  of  the  disease, 
but  they  do  not  produce  reabsorption  of  the  transudate  present 
in  the  air  vesicles.  If  there  is  but  a  small  quantity,  it  may  be 
expectorated  and  the  patient  tided  over  by  oxygen  inhalations. 
The  adrenal  preparations  are  powerful  vasoconstrictors  and  if 
there  is  cerebral  arteriosclerosis  they  may  produce  cerebral 
apoplexy,  but  the  gravity  of  pulmonary  edema  in  the  aged 
overbalances  the  possibility  of  producing  apoplexy.  The  rapidly 
acting  eliminants  are  powerful  cardiac  depressants  and,  if 
given,  they  must  be  combined  with  rapidly  acting  cardiac 
stimulants,  preferably  strychnine  and  digitalin.  This  applies 
especially  to  the  drastic  hydragogue  cathartics. 

PULMONARY  GANGRENE 

Etiology. — Gangrenous  destruction  of  lung  tissue  results 
from  the  action  of  putrefactive  bacteria  upon  diseased  tissue. 
It  is  always  a  secondary  disease,  most  frequently  following  an 
aspiration  or  deglutition  pneumonia,  or  other  form  of  pneumonia, 


PULMONARY   GANGRENE  2QI 

fetid  bronchitis  or  bronchiectasis,  cancer  or  tuberculosis.  It 
may,  however,  occur  in  any  pulmonary  affection  or  may  originate 
from  extraneous  sources  of  infection  such  as  a  perforating 
esophageal  cancer  or  empyema,  degenerating  bronchial  glands  or 
traumas.  A  non-putrid  gangrene  occasionally  occurs  in  the 
course  of  diabetes.  A  pulmonary  embolus  is  also  frequently 
followed  by  gangrene. 

Pathology. — Pulmonary  gangrene  may  be  acute  or  chronic, 
circumscribed  or  diffuse,  single  or  multiple.  The  tissue  becomes 
first  jelly-like,  then  softens  into  a  pultaceous  gray  or  greenish 
mass  of  fetid  matter  that  contains  shreds  of  tissue  which  had  not 
undergone  complete  destruction.  In  the  diffuse  form  this  mass 
extends  into  adjoining  healthy  tissue,  while  in  the  circumscribed 
form  the  mass  is  limited  by  a  growth  of  connective  tissue. 
Where  an  opening  into  a  bronchial  tube  exists,  the  mass  is  ex- 
pectorated and  the  cavity  may  become  completely  cleared.  An 
opening  into  the  pleural  cavity  may  cause  a  pyopneumothorax. 
There  is  usually  an  acute  or  a  fetid  bronchitis  and  often  a  pleurisy 
or  empyema  associated  with  pulmonary  gangrene. 

Symptoms. — This  disease  in  the  aged  is  usually  acute  and 
begins  with  active  symptoms  of  septic  infection,  such  as  irregular 
fever,  perspiration,  and  prostration.  The  severity  of  the  symp- 
toms depends  upon  the  extent  of  the  gangrene.  If  it  is  a  small, 
single,  localized  area,  symptoms  will  be  mild,  while  in  an  ex- 
tensive diffused  gangrene  there  will  be  high  fever,  rapid  prostra- 
tion and  emaciation,  finally  cerebral  symptoms  of  delirium  and 
coma  appear  and  death  soon  results.  An  early,  and  sometimes 
the  first,  symptom  of  pulmonary  gangrene  is  cough  with  fetid 
expectoration.  The  sputum  is  thin,  greenish  or  dark  gray  or 
brown  and  contains,  beside  mucus  and  pus,  bits  of  gangrenous 
tissue,  Dittrich's  plugs,  crystals  of  fatty  acids  and  under  the 
microscope  it  is  seen  to  be  loaded  with  bacteria.  The  odor  of 
the  sputum  is  the  decomposition  odor  of  nitrogenous  matter 
similar  to  the  odor  of  decaying  meat.  This  will  often  suffice  to 
distinguish  gangrene  from  abscess  of  the  lung  and  bronchiectasis, 
in  which  the  odor  is  due  to  fatty  acids  and  resembles  old  cheese. 
There  are  sometimes  traces  of  blood,  and  if  a  blood-vessel  be- 
comes necrotic  there  will  be  a  hemorrhage. 

Pulmonary  gangrene  in  the  aged  is  almost  invariably  fatal. 
Even  in  mild  cases  where  the  disease  is  localized  and  involves 


292 


PATHOLOGICAL    OLD   AGE 


only  a  small  area,  as  when  a  small  foreign  body  has  been  as- 
pirated, there  is  always  the  danger  of  diffusion  or  the  formation 
of  secondary  foci  through  aspiration  of  particles  of  putrid  matter 
from   the  bronchi.     Metastatic   abscesses   and   gangrene   may 

occur. 

Treatment. — Only  in  rare  instances  will  medical  measures 
avail,  while  operative  procedure  is  likewise  rarely  successful. 
The  medical  measures  are  the  inhalation  of  disinfectants,  such 
as  creosote,  guaiacol,  turpentine,  etc.,  and  the  internal  admin- 
istration of  powerful  expectorants  as  the  syrup  of  the  hypo- 
phosphite  of  ammonium  (contraindicated  in  tuberculosis), 
syrup  of  senega  or  ipecac  and  also  creosote,  guaiacol  and  similar 

drugs. 

The  strength  must  be  maintained  by  tonics,  concentrated 
foods,  and  small  quantities  of  alcohol,  while  incidental  symptoms, 
as  fever,  pain,  insomnia,  etc.,  must  receive  appropriate  treat- 
ment. It  is  possible  that  serum  therapy  holds  a  cure  for  this 
disease  but  at  present  the  only  chance  for  recovery,  slight  though 
it  be,  lies  in  operation. 

Pyopneumothorax. — Pneumothorax,  hydropneumothorax  and 
pyopneumothorax  are  rare  complications  of  pulmonary  gangrene 
and  occur  when  a  gangrene  or  abscess  opens  into  the  pleural 
cavity.  These  diseases  may  occur  from  any  cause  which  pro- 
duces an  opening  into  the  cavity  from  without,  or  from  the  lungs, 
pleural  or  abdominal  cavity.  They  are,  therefore,  liable  to  occur 
as  a  result  of  surgical  operations,  empyema,  tuberculosis,  abscess, 
or  gangrene  of  the  lung,  sudden  inspiratory  effort  causing  rup- 
ture of  alveoli  into  the  cavity  and  abscesses  of  the  abdom- 
inal cavity  opening  through  the  diaphragm  into  the  pleural 
cavity,  etc.  Pneumothorax  and  hydropneumothorax  are  ex- 
tremely rare,  and  when  they  occur  they  soon  become  infected. 
The  symptoms  which  usually  set  in  suddenly  are  pain  and  a 
sensation  of  tearing  in  the  lung,  dyspnea,  sometimes  cyanosis 
and  anxiety,  and  occasionally  expectoration  of  pus.  The  phys- 
ical signs  are  the  same  as  in  maturity,  the  auscultatory  signs 
being  especially  well  marked  in  later  life.  The  distention  of  the 
affected  side  is  not  marked  owing  to  the  rigidity  of  the  chest  walls, 
but  intercostal  distention  is  obliterated. 

A   cavity  of    a   pulmonary  tuberculosis  may  give   similar 
physical  signs  but  not  the  same  symptoms,  and  is  very  rare  in  old 


Fatty  degeneration  of  heart,  with  thickened  aortic 
leaflets  and  mitral  stenosis  (wooden  wedge  in  button- 
hole opening),  about  one-half  size.  (Satterthwaite, 
Medical  Record,  May  14.  iqio. 


0 


•I) 


Fatty  degeneration  of  cardiac  muscle,  a  beginning  changes;  b, 
plete  deegeneration,  X  250.  Satterthwaite,  Medical  Record, 
14,  ica°- 


corn- 
May 


PULMONARY  ABSCESS  293 

age.  Treatment  is  usually  fruitless,  as  the  causative  condition  is 
generally  of  a  fatal  nature.  Aspiration  may  give  temporary 
relief. 


PULMONARY  ABSCESS 

Etiology. — Abscess  of  the  lung  occurs  occasionally  in  old 
people,  most  frequently  as  a  secondary  complication  of  pneu- 
monia. In  influenza  the  bacilli  sometimes  cause  minute  ab- 
scesses in  the  lung,  and  the  aspiration  of  purulent  matter  from 
the  nose,  throat  or  bronchi  or  of  particles  of  food  may  also  occa- 
sion it.  Less  frequent  causes  are  perforation  of  the  lung  from 
an  empyema,  bronchiectasis  or  other  pus  cavity,  or  from  without 
as  from  bullet  wounds  and  other  trauma,  pyemia  with  the 
formation  of  metastatic  abscesses,  and  tuberculosis. 

Symptoms. — The  symptoms  in  the  aged  are  generally  vague, 
although  there  are  numerous  symptoms  and  signs  pointing  to 
pulmonary  disease  and  sometimes  to  septic  infection.  Where 
the  disease  follows  or  complicates  an  infectious  disease,  the 
earliest  symptom  is  a  purulent  expectoration.  The  pus  in  the 
sputum  is  mixed  with  mucus  and  does  not  form  coin-shaped 
plaques  as  in  purulent  bronchitis,  nor  lumps  as  in  tuberculosis. 
The  pus  cavities  in  the  senile  are  often  little  more  than  distended 
slits  in  the  tissues,  seldom  rounded  cavities  such  as  appear  in 
tuberculosis.  The  slit-like  cavities  are  usually  found  in  the 
lower  lobe,  the  round  cavities  in  the  upper  lobe  where  they 
simulate  tuberculosis  and  in  most  cases  a  bacteriological  exami- 
nation is  then  necessary  to  determine  whether  it  is  a  tubercular 
abscess  or  not.  The  physical  signs  of  pulmonary  abscess  in 
the  upper  lobe  are  the  same  as  in  tuberculosis.  The  tympanic 
percussion  note,  prolonged  expiration,  large  and  fine  moist 
rales  and  cough  with  expectoration  which  persists  day  and  night, 
all  point  to  a  cavity  which  is  constantly  being  emptied.  When 
the  abscess  is  in  the  lower  lobe  the  pus  collects  during  night  and 
necessitates  prolonged  coughing  and  expectoration  in  the  morn- 
ing, with  but  little  cough  or  expectoration  during  the  rest  of  the 
day. 

When  the  abscess  is  due  to  an  aspiration  or  deglutition 
pneumonia  there  is  little  or  no  elevation  of  temperature  but 
cachexia  with  anemia  and  emaciation  soon  sets  in.     The  sputum 


294  PATHOLOGICAL   OLD   AGE 

becomes  purulent  and  shows  on  standing  the  characteristic 
layers  of  purulent  expectoration.  The  heavy  grayish  lower  layer 
contains  bacteria,  leucocytes,  fatty  acids,  and  elastic  fibers.  This 
layer  has  a  foul,  and  in  an  old  abscess,  a  fetid  necrotic  odor. 
The  middle  layer  is  grayish  and  watery  and  if  a  blood-vessel 
has  been  involved  the  liquid  will  be  colored  red  or  brown.  The 
upper  layer  is  mucus  and  contains  air  cells.  The  sputum  of 
bronchiectasis  is  similar,  and  a  deep-seated  bronchiectasis  in 
the  lower  lobe  often  gives  signs  similar  to  the  physical  signs  of 
abscess.  In  these  cases  the  more  rapid  development  and  the 
cachexia  point  to  abscess,  but  the  history  may  be  necessary  to 
determine  the  diagnosis. 

Treatment. — The  only  certain  method  of  emptying  a  pus 
cavity  in  the  lung  is  by  operative  procedure,  aspiration,  or  by 
resection  of  ribs  and  then  aspiration.  The  uncertainty  of  the 
exact  situation  of  the  abscess  makes  rib  resection  the  better 
course,  but  the  method  must  be  left  to  the  surgeon.  If  the 
local  and  constitutional  symptoms  are  mild,  medicinal  measures 
can  be  employed  to  favor  emptying  of  the  pus  cavity  by  expec- 
toration. This  can  sometimes  be  accomplished  through  the 
inhalation  of  guaiacol  or  creosote,  the  internal  administration 
of  expectorants  as  muriate  of  ammonia,  syrup  of  senega  and 
ipecac,  and  a  posture  which  will  permit  the  free  flow  of  the 
sputum  toward  the  mouth.  This  can  be  produced  by  raising 
the  foot  of  the  bed.  The  use  of  hygienic  regulations,  fresh  air, 
concentrated  food,  tonics,  etc.,  is  self-evident. 

CARDIAC  HYPERTROPHY 

Simple  hypertrophy  is  normal  in  the  aged,  the  increasing 
hyperplasia  keeping  pace  with  the  increase  in  the  resistance  of 
the  vessels,  caused  by  arteriosclerosis. .  In  the  physiological 
hypertrophy  the  left  ventricle  alone  is  involved  but  there  is  no 
increase  in  the  size  of  the  cavity.  When  the  walls  of  any  of  the 
other  cavities  become  hypertrophied  or  dilatation  sets  in  we 
have  a  pathological  condition  to  deal  with. 

Etiology. — Cardiac  hypertrophy  is  the  result  of  excessive 
work,  the  muscle  tissue  increasing  as  all  striped  muscles  increase 
in  volume,  when  actively  employed. 

The  principal  causes  for  left  ventricular  hypertrophy  are 


CARDIAC   HYPERTROPHY  295 

increased  arterial  resistance  as  in  arteriosclerosis,  nephritis, 
or  as  a  result  of  vasoconstrictor  drugs;  or  toxic  irritation  as  in 
uremia,  goiter,  gout,  and  infectious  diseases;  cardiac  defects  as 
valvular  disease  or  myocarditis,  or  pericardial  adhesions ;  finally 
excessive  or  prolonged  exercise  as  in  athletic  sports. 

Right  ventricular  hypertrophy  occurs  when  there  is  some 
obstruction  to  the  circulation  in  the  lungs,  as  in  emphysema,  or 
when  there  is  mitral  disease  present.  Pericardial  adhesions 
may  cause  excessive  work  for  the  ventricular  muscle  and  produce 
hypertrophy. 

Auricular  hypertrophy  is  invariably  accompanied  by  dilata- 
tion and  is  due  to  valvular  disease. 

Pathology. — The  heart  is  increased  in  size,  it  is  rounder 
and  less  pointed  than  in  its  normal  state.  If  the  hypertrophy 
is  confined  to  the  left  ventricle,  the  heart  is  pear  shaped,  but 
if  both  ventricles  are  involved  it  is  longer  and  oval.  The  walls 
may  be  increased  to  twice  their  normal  size,  the  increase  being 
hyperplastic  (numerical  hypertrophy). 

Symptoms. — In  the  simple  hypertrophy  of  old  age  associated 
with  arteriosclerosis  there  are  no  symptoms  referable  to  the 
heart  as  long  as  the  heart's  action  is  not  disturbed.  Exercise 
or  excitement  will  produce  palpitation  and  may  produce  cerebral 
hyperemia  with  headache,  vertigo  and  tinnitus.  At  such  times 
the  face  becomes  flushed,  there  may  be  a  nervous  twitching  and 
psychic  manifestations,  such  as  irritability  of  temper,  may  appear. 
Similar  symptoms  are  produced  when  there  is  cardiac  irritation 
from  a  distended  stomach.  In  the  hypertrophy  associated  with 
other  cardiac  lesions  the  symptoms  of  the  latter  mask  the  symp- 
toms of  the  hypertrophy. 

The  physical  signs  in  left  ventricular  hypertrophy  are  an 
increased  area  of  impulse  and  visible  cardiac  pulsation,  an  in- 
creased area  of  the  apex  beat  to  the  left  of  and  below  its  normal 
position,  percussion  dulness  is  increased  to  the  left  and  downward, 
and  the  heart  sounds  are  increased  in  intensity,  the  first  sound 
being  dull  and  prolonged. 

In  right  ventricular  hypertrophy  there  is  epigastric  pulsation, 
the  apex  beat  is  displaced  to  the  right  and  downward,  percussion 
dulness  is  increased  to  the  right  of  the  sternum,  and  the  second 
sound  is  heard  loudest  over  the  pulmonic  orifice.  In  auricular 
hypertrophy  and  dilatation  the  percussion  area  is  increased  up- 


296  PATHOLOGICAL   OLD   AGE 

ward.  Except  in  simple  hypertrophy  of  the  left  ventricle  the 
symptoms  and  signs  are  modified  by  the  accompanying  lesions 
and  if  there  is  dilatation  present,  all  of  these  may  be  altered 
except  the  area  of  percussion  dulness.  Hypertrophy  is  differ- 
entiated from  dilatation  by  the  regularity  and  strength  of  the 
heart  action,  by  the  more  intense  second  sound,  absence  of  mur- 
murs and  absence  of  symptoms  referable  to  pulmonary  engorge- 
ment. 

With  increasing  arterial  resistance  there  is  an  increasing 
hypertrophy  to  a  point  where  the  limit  of  functional  capacity 
is  reached.  Beyond  this  point  compensation  is  broken,  dilata- 
tion ensues  and  the  further  progress  is  the  history  of  cardiac 

dilatation. 

Treatment. — The  main  indication  in  the  treatment  of  simple 
hypertrophy  is  to  maintain  compensation  and  to  defer  as  long  as 
possible  the  inevitable  break  when  the  limit  of  the  functional 
capacity  is  reached.  If  there  is  an  underlying  pathological 
condition  this  must  receive  attention.  Hygienic  measures 
must  be  taken  to  prevent  intense  or  prolonged  mental  and 
physical  strain,  excesses  or  fatigue.  Heart  stimulants  are  con- 
traindicated  and  only  in  case  of  palpitation  following  excessive 
exercise  or  in  case  of  fever  are  cardiac  sedatives  like  aconite  or 
veratrum   permissible.     Alcohol    must    be    strictly    forbidden. 

CARDIAC  DILATATION 

Cardiac  dilatation  is  an  increase  in  the  size  of  the  cavities. 
It  is  invariably  a  secondary  condition  either  following  a  hyper- 
trophy which  has  reached  the  limit  of  its  functional  capacity  or 
some  other  condition  which  has  impaired  the  tonicity  of  the 
heart  muscle.  There  is  a  limit  to  the  working  capacity  of  muscle 
fibers,  but  prolonged  or  excessive  work  produces  fatigue  before 
this  limit  is  reached^^urther  activity  can  be  aroused  only 
under  a  forced  stimulus,  until  exhaustion  sets  in  with  complete 
inability  to  work  under  any  stimulus.  Fatigue  demands  rest 
and  exhaustion  compels  rest,  during  which  recuperation  and 
repair  take  place.  Every  contraction  of  the  heart  is  followed  by 
a  short  refractory  period  during  which  it  cannot  respond  to  stim- 
ulation. This  corresponds  to  the  rest  period  following  exhaus- 
tion.    With  the  increasing  arterial  resistance,  due  to  arterio- 


CARDIAC   DILATATION  297 

sclerosis,  the  work  of  the  heart  is  increased  and  this  is  made  pos- 
sible by  an  increase  in  the  number  of  muscle  fibers  or  hyperplasia 
of  tissue.  Gradually  the  work  increases  more  rapidly  than  the 
increase  in  tissue  can  keep  pace  with,  while  the  rest  period  is  not 
prolonged  proportionately  and  the  muscle  finally  reaches  the 
point  of  the  limit  of  its  functional  capacity.  Then,  being  un- 
able to  respond  to  further  increased  activity,  the  fibers  begin  to 
degenerate,  lose  their  tonicity,  stretch  and  cannot  contract  fully. 
Thus  is  then  produced  a  distention  of  the  walls  with  dilatation 
of  the  chambers.  In  some  cases  this  is  brought  about  by  the 
weakening  of  the  walls  through  malnutrition.  In  other  cases 
the  internal  tension  is  greatly  increased  and  the  tonicity  of  the 
muscle  fibers  is  thus  impaired.  This  may  occur  during  prolonged 
strain  and  it  may  occur  rapidly  or  even  suddenly  upon  any  vio- 
lent and  sudden  exertion.  In  most  cases,  however,  the  in- 
ception of  the  dilatation  arises  from  increased  internal  tension 
as  soon  as  the  limit  of  the  functional  activity  of  the  heart  muscle 
is  reached. 

Etiology. — There  are  three  general  causes  for  cardiac  dilata- 
tion: (1)  exceeding  the  limit  of  the  functional  capacity  of  the 
heart,  (2)  degeneration  of  the  heart  and  (3)  increased  internal 
pressure.  The  first  is  the  usual  cause  in  senile  cases,  and  the 
method  of  production  has  been  explained.  The  second,  i.e., 
degeneration  of  the  heart,  may  be  due  to  the  process  of  involu- 
tion, to  toxins,  especially  that  of  pneumonia,  to  typhoid  fever, 
influenza,  erysipelas  and  other  diseases  accompanied  by  pyrexia, 
or  to  malnutrition.  In  these  cases  there  is  usually  no  change  in 
the  thickness  of  the  walls.  The  third,  or  increased  internal 
pressure,  may  occur  secondarily  to  cardiac  weakness  with  im- 
paired circulation,  the  auricles  becoming  overdistended  while  the 
ventricles  are  unable  to  completely  empty  themselves.  This 
may  occur  in  myocardial  degeneration,  valvular  disease  or 
arteriosclerosis.  Increased  internal  pressure  may  also  be  pro- 
duced by  the  ingestion  of  large  quantities  of  fluids.  The  so- 
called  "Munchner  Bier  Herz"  is  a  cardiac  dilatation  due  to  this 
cause.  Sudden  or  prolonged  exertion  as  in  violent  athletic 
sports  may  produce  a  rapid  dilatation  from  increased  internal 
pressure.  This  is  the  usual  cause  of  death  of  contestants  just 
after  a  supreme  effort  on  the  athletic  field.  In  these  cases  the 
walls  of  the  heart  are  generally  thin. 


298  PATHOLOGICAL    OLD   AGE 

Pathology. — The  cardiac  walls  may  be  normal,  hypertrophied 
or  thin.  In  senile  cases  there  is  usually  hypertrophy  and  all 
chambers  are  dilated.  In  other  cases  the  right  ventricle  is 
first  dilated  followed  by  the  left  auricle,  right  auricle  and  lastly 
the  left  ventricle.  There  is,  however,  no  uniformity  in  the  order 
in  which  the  chambers  become  dilated  and  in  some  cases  of  myo- 
cardial degeneration  the  dilatation  is  localized  over  the  seat  of 
the  degeneration.  The  muscle  fibers  show  degenerative  changes 
and  frequently  the  nerve  ganglia  are  altered.  The  venae  cavae 
are  generally  dilated  if  the  right  auricle  is  dilated.  Dilatation 
is  generally  associated  with  valvular  disease  and  the  valves  show 
the  well-known  changes  in  structure  and  anatomical  relations. 

Symptoms. — The  symptoms  vary  with  the  form  of  dilatation. 
If  there  is  a  cardiac  hypertrophy  there  may  be  a  progressive  di- 
latation without  any  symptoms,  or  with  symptoms  masked  or 
counterbalanced  by  the  symptoms  of  hypertrophy  until  dilatation 
becomes  more  marked  or  until  a  sudden  strain  produces  a  sudden 
or  rapidly  increasing  dilatation.  When  occurring  suddenly  or 
rapidly  there  is  a  severe  pain  in  the  cardiac  region,  dyspnea  and 
weak,  rapid  or  irregular  heart  action.  If  coming  on  slowly  there 
is  but  a  gradual  weakening  of  heart  action  and  but  occasional 
shortness  of  breath.  These  symptoms  may  be  present  for 
months  before  they  are  sufficiently  severe  to  attract  the  atten- 
tion of  the  patient.  In  cases  not  accompanied  by  hypertrophy, 
the  symptoms  appear  more  rapidly  and  are  more  pronounced 
from  the  beginning.  In  the  form  especially  in  which  the  walls 
are  thinner  than  normal,  the  early  symptoms  are  quite  marked. 
In  these  cases  there  is  palpitation,  arrhythmia,  in  which  the  rate 
is  irregular  and  the  force  diminished,  the  pulmonary  circulation 
becomes  impeded  and  there  is  incomplete  aeration  of  blood  and 
dyspnea  on  slight  exertion,  the  arteries  are  incompletely  filled 
and  the  veins  are  distended.  As  the  dilatation  increases  there  is 
a  constant  palpitation  or  a  feeling  of  throbbing  and  irregular 
wobbling  of  the  heart,  the  dyspnea  becomes  permanent,  the 
face  is  pale,  the  lips  cyanotic  and  on  excitement  the  entire  face 
becomes  livid  or  cyanotic.  The  pulse  is  irregular  and  weak. 
Irritability  results,  followed  later  by  diminished  mental  power. 
When  the  disease  is  far  advanced,  the  symptoms  become  more 
marked,  there  is  cyanosis,  scanty  albuminous  urine,  edema, 
occasional  syncope,  later  the  liver,  spleen,  kidneys  and  stomach 


CARDIAC   DILATATION  299 

become  involved  through  defective  circulation  and  impaired 
venous  return  and  their  functions  are  disturbed.  Dropsy  may- 
increase  until  there  is  general  anasarca,  but  in  the  aged,  death 
usually  occurs  from  pulmonary  edema  before  the  dropsy  is  far 
advanced. 

The  principal  physical  signs  are  the  increased  area  of  dulness 
with  short,  feeble  heart  sounds.  There  is  often  arrhythmia, 
either  the  galloping  arrhythmia  or  embryocardia.  There  is  an 
indistinct  and  increased  area  of  cardiac  impulse  with  a  diffused 
and  weak  apex  beat.  In  thin  persons  a  wavy  movement  over 
the  precardial  space  can  be  seen  and  felt.  Occasionally  a  thrill 
can  be  felt  and  if  the  right  heart  is  affected  the  jugulars  are  prom- 
inent and  dilated.  As  dilatation  is  usually  associated  with  val- 
vular disease  there  are  also  the  symptoms  and  signs  of  the  re- 
spective valvular  lesion.  In  senile  cases  the  pulse  is  of  no  service 
in  determining  the  diagnosis.  It  is  usually  weak,  irregular  and 
intermittent  but  when  the  radial  artery  is  sclerosed  it  may  be 
hard,  while  beats  may  be  lost  in  transmission  from  the  heart  to 
the  wrist. 

Diagnosis. — Observation  of  the  physical  signs  ought  to 
differentiate  dilatation  from  hypertrophy  in  which  the  impulse, 
apex  beat  and  heart  sounds  are  strong  and  clearly  defined. 
In  thoracic  aneurysm  and  mediastinal  tumors  the  area  of  dul- 
ness is  upward.  In  pericarditis  with  effusion  the  area  of  dulness, 
friction  sounds,  regular  rhythm,  and  absence  of  vesicular  mur- 
mur in  the  parts  of  the  lung  covered  by  the  effusion  will  clear  up 
the  diagnosis. 

Prognosis. — The  prognosis  in  senile  cases  is  bad.  The  dis- 
ease is  incurable  and  sometimes  rapidly  fatal.  If  it  follows  an 
aortic  insufficiency  or  stenosis  it  usually  runs  a  regular  course; 
i.e.,  relative  mitral  insufficiency,  dilatation  of  the  left  auricle, 
pulmonary  engorgement,  hypertrophy  and  dilatation  of  the 
right  ventricle,  then  of  the  right  auricle,  with  general  venous  en- 
gorgement. This  is  the  order  of  cardiac  involvement  but  it  may 
proceed  rapidly  or  slowly  or  one  or  more  stages  may  pro- 
ceed more  rapidly  than  others.  Dilatation  following  diffuse 
myocardial  degeneration  proceeds  rapidly  and  there  is  no  order 
in  the  valvular  involvement.  Sometimes  pulmonary  engorge- 
ment evidenced  by  dyspnea  and  cyanosis  occur  soon  after  the 
initial  symptoms  of  degeneration  appear.     Life  can  usually  be 


3<DO  PATHOLOGICAL   OLD   AGE 

prolonged  with  care  and  treatment,  but  death  will  result  from 
cardiac  exhaustion,  pulmonary  edema  or  from  degeneration  of 
some  other  organ.  Treatment  is  the  same  as  that  of  valvular 
lesions. 

FATTY  DEGENERATION  OF  THE  HEART 

Fatty  degeneration  when  occurring  in  the  aged  is  generally 
due  to  impaired  nutrition  through  sclerosis,  embolism  or  throm- 
bosis of  the  coronaries.  It  may  follow  fatty  infiltration  or 
occur  in  the  progress  of  cancer.  It  is  not,  however,  a  true 
senile  degeneration.  It  is  assumed  that  where  fatty  infiltration 
exists,  fat  makes  its  way  into  the  muscle  cells.  In  other  cases 
protoplasmic  activity  is  impaired  and  instead  of  reproducing 
protoplasm  it  produces  a  suboxidation  product,  fat.  According 
to  this  view  fatty  degeneration  is  secondary  to  a  primary 
degeneration  due  to  impaired  nutrition. 

Etiology. — Fatty  degeneration  may  occur  at  any  period  of 
life  and  the  "same  causes  to  which  it  may  be  due  in  earlier  life  may 
produce  it  in  old  age.  The  predisposing  causes  are,  insufficient 
nutrition  as  from  coronary  sclerosis  or  from  the  general  mal- 
nutrition of  old  age,  from  perverted  nutrition  as  in  general 
obesity  and  from  fatty  infiltration.  These  may  also  be  the 
exciting  causes.  It  may  also  occur  in  the  course  of  infectious 
diseases,  cachexias,  Bright's  disease,  chronic  alcoholism,  phos- 
phorus and  arsenic  poisoning,  pericarditis,  cardiac  hyper- 
trophy, etc. 

Pathology. — If  the  degeneration  is  general,  the  heart  may  be 
enlarged,  pale  or  yellowish  and  flabby,  resembling  fatty  infiltra- 
tion, or  it  may  show  little  or  no  change.  In  many  cases  the 
degeneration  is  localized,  involving  the  walls  of  a  single  chamber 
or  of  a  still  smaller  area. 

The  muscle  fibers  lose  their  nuclei  and  striations,  become 
granular  and  the  sarcolemma  is  filled  with  granules.  When 
the  disease  is  far  advanced  the  whole  muscle  cell  seems  to  be 
filled  with  fat  granules  and  oil  globules.  The  disease  rarely 
proceeds  to  that  degree  in  the  aged,  as  the  whole  heart  is  usually 
involved  in  these  cases  and  owing  to  the  general  senile  impair- 
ment of  the  organ,  dilatation  and  its  consequences  follow  early. 

Symptoms.— There  are  no  early  symptoms  indicating  fatty 
degeneration  and  there  may  be  no  change  in  the  function  of 


Abnormal  deposition  of  fat,  X845.     (Satterthwaite. 

Medical  Record,  May  14,  1910.) 


FATTY   INFILTRATION   OF    THE   HEART 


30I 


the  heart  until  dilatation  sets  in.  As  the  disease  progresses 
there  are  usually  symptoms  of  defective  heart  power,  rapid 
exhaustion  and  palpitation  or  arrhythmia  upon  exercise, 
dyspnea,  giddiness,  vertigo  and  syncope  due  to  cerebral  anemia, 
feeble  pulse  and  apex  beat,  and  upon  auscultation  the  heart 
sounds  are  found  to  be  feeble  and  the  first  sound  almost  inaudi- 
ble. The  respiration  is  generally  feeble  and  sighing  with 
occasional  attacks  of  cardiac  asthma  and  in  extreme  cases  the 
Cheyne-Stokes  type  of  respiration  may  appear.  Irritability  of 
temper,  probably  due  to  cerebral  anemia — a  prominent  symp- 
tom in  all  cardiac  affections  producing  cardiac  weakness — is  an 
early  symptom  of  fatty  degeneration.  An  increased  area  of 
percussion  dulness  before  .'dilatation  may  be  due  to  hypertrophy 
or  fatty  infiltration. 

After  dilatation  has  set  in  the  symptoms  are  referable  to 
that  condition.  Death  may  result  from  sudden  strain  or 
emotion. 

Treatment. — The  treatment  of  fatty  degeneration  is  symp- 
tomatic and  hygienic  before  dilatation  takes  place,  the  object 
being  to  prevent  failing  compensation.  Mental  and  physical 
exertion  must  be  avoided,  especially  sudden  strains  and  emotions. 
High  altitudes  are  injurious.  Alcohol  and  tobacco  are  inter- 
dicted, liquids  should  not  be  taken  with  foods  and  the  food 
should  be  easily  digestible  for  prompt  assimilation.  Constipa- 
tion should  be  guarded  against.  Mild  exercise  is  permitted 
but  the  patient  must  constantly  bear  in  mind  that  a  sudden  strain 
may  cause  death.  The  Oertel  terrain  treatment  and  the 
Schott  and  Nauheim  treatments  are  dangerous  in  old  age. 
Digitalis  is  contraindicated,  but  in  an  emergency,  when  lost 
compensation  has  brought  about  a  critical  condition  with  irregu- 
lar, rapid,  weak  heart  and  dyspnea,  and  there  is  danger  of  cardiac 
exhaustion,  and  strychnia,  carbonate  of  ammonia,  aromatic 
spirits  of  ammonia  and  other  cardiac  stimulants  have  failed, 
we  are  justified  in  giving  hypodermically  digitalin  combined 
with  nitroglycerin  in  doses  of  1/100  grain  each. 

FATTY  INFILTRATION  OF  THE  HEART 

Fatty  infiltration  is  not  a  degeneration  nor  a  senile  disease, 
although  it  occurs  most  frequently  in  obese  persons  after  middle 
age. 


302  PATHOLOGICAL    OLD   AGE 

Etiology. — In  most  cases  it  is  part  of  the  general  process  of 
suboxidation  which  causes  obesity  and  is  due  to  the  same 
metabolic  disturbance.  It  occurs  mostly  in  women  past  the 
menopause  and  in  men  after  the  critical  period  which  occurs 
about  the  fiftieth  year.  The  underlying  cause  of  obesity  which 
frequently  appears  about  this  time  is  unknown. 

Pathology. — Fat  deposits  around  the  heart,  between  the 
auricles,  in  the  auriculo-ventricular  groove,  about  the  right 
ventricle  and  between  the  bundles  of  muscle.  The  heart 
appears  larger  and  is  pale  or  yellow  and  flabby.  In  advanced 
cases  there  is  usually  fatty  degeneration  and  dilatation. 

Symptoms. — There  are  no  early  signs  or  symptoms.  It  may 
be  suspected  when  with  increasing  obesity  there  is  dyspnea 
upon  exertion  and  percussion  reveals  an  increasing  area  of  dul- 
ness.  With  the  increase  of  fat  about  and  in  the  heart,  the  heart 
muscle  finds  it  more  difficult  to  do  its  work,  the  heart  becomes 
weakened  and  dilatation  ensues.  If  fatty  degeneration  sets 
in,  the  dilatation  proceeds  more  rapidly  and  the  symptoms 
of  that  disease  prevail. 

Treatment. — The  treatment  of  fatty  infiltration  is  the  treat- 
ment of  general  obesity.  When  degeneration  or  dilatation  sets 
in,  the  treatment  must  be  directed  to  the  new  condition. 

VALVULAR  LESIONS 

Valvular  defect  of  some  kind  is  found  in  most  senile  hearts, 
but  they  give  no  subjective  symptoms  as  long  as  a  compensatory 
hypertrophy  exists.  When  compensation  is  broken  and  dilata- 
tion sets  in,  the  symptoms  become  marked  and  the  secondary 
diseases  due  to  impaired  circulation  and  venous  engorgement 
quickly  follow.  The  most  frequent  defects  are  aortic  insuf- 
ficiency, aortic  stenosis  and  mitral  insufficiency.  Uncompli- 
cated mitral  stenosis  is  rare  as  the  principal  causative  factor, 
acute  endocarditis  following  rheumatism,  infectious  disease  or 
toxin  rarely  occurs  in  old  age. 

The  underlying  cause  of  stenosis  in  old  age  is  atheroma,  either 
originating  in  the  valve  itself  or  extending  to  the  valve  from  senile 
endocarditis  or  aortic  atheroma.  Insufficiency  may  be  due  to 
atheroma,  cardiac  dilatation  or  myocardial  disease.  There  are, 
however,  cases  of  aortic  insufficiency  in  which  the  valve  itself 


Tracing  of  Pulse  in  Mitral  Stenosis.   (From  Tyson  and  Fussell's 
"Practice  of  Medicine.") 


Pulse-tracing    of    Aortic    Stenosis.     (From  Tyson  and  Fussell's 
"Practice  of  Medicine.") 


Tracing  of  Pulse  of  Mitral  Insufficiency.     (From  Tyson  and 
Fussell's  "Practice  of  Medicine.") 


Tracings  of  Pulse  of  Aortic  Regurgitation.     (From  Tyson  and 
Fussell's  Practice  of  Medicine.") 


Sphygmogram    of    an    Atheromatous    Vessel — The    Pulsus 
Tardus.     (From  Tyson's  "Practice  of  Medicine.") 


VALVULAR    LESIONS 


3°3 


is  not  diseased  but  in  which,  owing  to  a  dilatation  of  the  aorta,  the 
aortic  ring  is  overstretched  and  cannot  close  completely. 
Preble  has  reported  a  similar  relative  insufficiency  of  the  pul- 
monary valves.  As  a  result  of  atheroma  and  degenerative 
changes  in  its  structure,  a  valve  may  be  both  thickened  and  con- 
tracted producing  insufficiency  and  stenosis  at  the  same  time. 
In  some  cases  the  mitral  and  aortic  valves  are  involved,  the 
mitral  involvement  being  usually  secondary  to  the  aortic  disease. 

As  long  as  the  hypertrophied  heart  can  compensate  for  the 
impairment  of  the  circulation  caused  by  diseased  valves  and 
sclerosed  vessels,  there  may  be  little  or  no  disturbance  in  the 
circulation  and  no  marked  symptoms  of  valvular  disease,  though 
the  physical  signs  may  be  pronounced.  When  decompensation 
sets  in,  the  symptoms  of  cardiac  dilatation  prevail,  modified  or 
accentuated  by  the  symptoms  of  the  valvular  lesion.  Patients 
having  valvular  disease  in  early  life  rarely  reach  old  age  and  the 
valvular  diseases  found  in  the  aged  usually  originate  at  that 
period  of  life. 

The  diagnosis  of  valvular  disease  in  the  aged  is  not  difficult 
if  there  is  but  a  single  valvular  defect.  If  there  are  two  or  more 
defects  a  discerning  ear  may  be  able  to  distinguish  the  separate 
murmurs,  but  other  physical  signs  and  the  symptoms  may  be  too 
complicated  to  be  interpretable.  A  disturbing  factor  in  these 
cases  is  the  atheromatous  aorta  which  adds  its  own  train  of 
symptoms.  Where  there  is  arrhythmia  with  a  variable  cardiac 
impulse  the  carotid  pulsation  will  serve  to  determine  the  systolic 
sound.  A  frequent  source  of  error  in  diagnosing  valvular  lesions 
is  the  altered  position  of  the  heart.  In  the  aged  the  second  sound 
is  heard  loudest  in  the  third  intercostal  space  and  if  the  heart  is 
greatly  atrophied  it  may  be  most  intense  in  the  fourth  intercostal 
space. 

If  degenerative  changes  originate  in  the  valves,  they  begin  by 
a  thickening  of  the  edge  which  becomes  opaque,  firm  and  in- 
elastic. In  the  aortic  valve  the  degenerative  change  begins  in 
the  corpus  Arantii,  and  in  the  mitral  valve  at  the  margin  of  the 
leaflets.  The  endothelial  covering  undergoes  the  same  changes 
as  that  of  the  arteries  including  ulceration  and  deposit  of  fatty 
and  calcareous  plaques.  The  valves  may  be  thickened  and 
contracted,  appearing  like  misshapen  pedicles  which  diminish 
the  size  of  the  orifice  but  cannot  fully  close  it.     The  distorted 


304  PATHOLOGICAL   OLD    AGE 

valves  may  take  different  forms  and  produce  various  shaped 
orifices,  increasing  or  diminishing  the  size  of  the  openings, 
partially  blocking  them  or  permitting  any  degree  of  regurgita- 
tion. Calcification  is  a  late  degenerative  change.  When  this 
occurs  decompensation  rapidly  ensues  and  the  impairment  to 
the  circulation  caused  by  the  weakened  heart  produces  rapid 
degeneration  in  other  organs  and  tissues. 

Before  taking  up  the  valvular  lesions  in  detail  a  few  diagnostic 
points  applicable  to  senile  cases  will  be  given  as  follows. 

A  murmur  or  abnormal  sound  is  heard  when  the  blood  is  sent 
against  a  resistance  at  the  orifice  or  when,  in  the  rebound,  the 
blood  returns  to  a  cavity  through  an  incompletely  closed  orifice, 
or  if  the  valves  are  roughened.  In  the  first  case  the  valve  does 
not  open  completely  and  there  is  an  obstruction  or  stenosis. 
This  is  due  to  a  thickened  or  distorted  valve  or  to  a  growth  at  the 
orifice.  In  the  second  case  the  valve  does  not  close  completely 
and  we  get  a  regurgitation  or  as  it  is  usually  called  incompetence 
or  insufficiency.  This  may  be  due  to  a  defect  of  the  valve  or  it 
may  be  due  to  a  dilatation  of  the  cavity  or  of  the  aorta,  whereby 
the  orifice  is  stretched.  The  diagnosis  of  a  valvular  lesion  is  made 
primarily  by  the  location  of  the  murmur  and  the  time  of  its  oc- 
currence in  the  cardiac  cycle.  The  obstructive  murmurs  are 
heard  loudest  over  the  valve,  the  regurgitant  murmurs  are  heard 
loudest  back  of  the  valve  in  the  cavity  into  which  the  blood  re- 
bounds, the  former  are  carried  forward  in  the  direction  of  the 
flow,  while  the  latter  are  carried  in  the  direction  of  the  rebound. 
We  can  thus  localize  mitral  murmurs  about  the  apex,  aortic  mur- 
murs near  the  base  to  the  right  or  left  of  the  sternum  and  tri- 
cuspid murmurs  behind  the  middle  of  the  sternum.  Pulmonic 
murmurs  and  tricuspid  stenosis  are  extremely  rare,  and  occur 
only  when,  through  loss  of  compensation  and  myocardial  degen- 
eration, all  the  valves  break  down.  In  point  of  time  the  aortic 
stenosis  occurs  during  the  systolic  contraction,  while  aortic 
regurgitation  occurs  after  the  blood  has  left  the  heart  and  a 
small  quantity  is  forced  back  by  the  contraction  of  the  aorta. 
This  occurs  during  diastole.  The  auricles  contracting  imme- 
diately before  the  ventricles,  a  mitral  or  tricuspid  obstruction 
sound  would  occur  therefore  immediately  before  the  systole  or 
in  the  presystolic  period.  A  mitral  or  a  tricuspid  insufficiency 
permits  the  return  of  blood  from  the  ventricle  during  the  con- 


VALVULAR   LESIONS  305 

traction  of  that  chamber,  therefore  the  murmurs  of  these  lesions 
occur  during  the  systolic  period.  Abrahams  has  shown  how  the 
valvular  lesions  affect  the  pulse  when  the  arm  is  held  in  different 
positions.  In  aortic  regurgitation,  if  the  arm  is  raised  in  a 
vertical  position,  the  jerking,  collapsing  pulse  is  felt  at  an  early- 
stage  of  the  disease  and  this  variety  of  pulse  remains  throughout 
this  disease.  The  pulse  in  aortic  stenosis  is  slow  and  weak  and 
it  does  not  change  in  whatsoever  position  the  arm  is  placed.  In 
mitral  stenosis  the  pulse  is  weak  and  if  the  arm  is  held  in  a 
vertical  position  over  the  head  the  pulse  may  disappear.  In 
mitral  regurgitation  the  pulse  is  weak,  when  the  arm  is  held  in  a 
vertical  position  and  reappears  strongly  when  held  in  a  horizontal 
position.  When  compensation  is  lost  the  pulse  in  mitral  disease 
disappears  entirely  upon  raising  the  arm  over  the  head. 

In  radial  arteriosclerosis  these  characteristics  may  not  ap- 
pear, and  the  radial  pulse  may  be  so  weak  in  any  position  as  to 
be  hardly  appreciable.  Errors  may  occur  if  two  murmurs  are 
heard  at  the  same  time.  The  only  diastolic  murmur  occurring 
in  the  aged  is  the  aortic  regurgitant  murmur.  The  aortic 
obstructive  and  the  mitral  and  tricuspid  regurgitant  murmurs 
occur  during  the  systole,  but  the  aortic  murmur  is  never  heard  at 
the  apex,  the  mitral  murmur  is  heard  over  the  apex  and  to  the 
left  and  is  often  heard  at  the  back,  the  tricuspid  is  heard  to  the 
right  of  the  sternum.  As  diastole  begins  with  the  beginning  of 
the  second  sound  we  must  be  certain  about  the  two  sounds  and 
if  there  is  any  doubt  as  to  which  is  the  first  and  which  the  second 
we  must  find  the  apex  beat  or  the  carotid  pulse,  thus  determining 
the  systole.  The  radial  pulse  is  useless  for  this  purpose.  An 
hour-glass  murmur,  one  which  is  heard  loudest  at  one  valve, 
gradually  growing  weaker  to  a  certain  point,  then  again  increas- 
ing in  intensity  as  we  approach  another  valve,  indicates  that  the 
two  valves  are  diseased.  In  the  aged  this  happens  most  fre- 
quently in  aortic  obstruction  and  mitral  regurgitation. 

Presystolic  murmurs  are  heard  best  when  the  patient  is  sitting 
or  standing  up,  systolic  murmurs  are  heard  best  when  the  patient 
is  lying  down  and  the  murmur  of  tricuspid  regurgitation  can 
sometimes  be  heard  only  in  Stern's  posture,  lying  down  with  the 
head  slightly  lowered  so  as  to  stretch  the  vessels  of  the  neck. 
Diastolic  murmurs  are  not  affected  by  position. 

All  murmurs  heard  in  the  region  of  the  heart  are  not  due  to 
20 


306  PATHOLOGICAL   OLD    AGE 

valvular  lesions  nor  do  all  cardiac  murmurs  imply  diseased 
valves.  There  may  be  a  relative  insufficiency  in  which  the  orifice 
is  enlarged  so  that  the  valve  cannot  close  it  completely,  yet  the 
valve  will  be  sound.  The  Austin  Flint  murmur  sometimes  heard 
near  the  apex  in  aortic  regurgitation  may  simulate  the  murmur 
of  mitral  stenosis  and  is  in  the  locality  in  which  mitral  murmurs 
are  usually  heard,  yet  it  has  apparently  no  connection  with 
mitral  disease. 

Functional  or  accidental  murmurs  are  infrequent  in  the  aged, 
as  the  probable  cause,  pressure  upon  or  suction  of  the  over- 
lapping edges  of  the  lungs  by  the  cardiac  contractions,  does 
not  prevail  where  the  lungs  are  atrophied.  In  anemia  or 
debility,  leakage  may  occur  through  the  mitral  or  tricuspid 
valve.  This  real,  though  temporary  relative  insufficiency  is 
not  an  organic  defect.  The  pericardial  friction  sounds  and 
cardiorespiratory  murmurs  are  affected  by  the  respiration  and 
there  is  a  history  pointing  to  the  underlying  cause. 

AORTIC  REGURGITATION 

The  author  has  found  this  one  of  the  most  frequent  valvular 
lesions  in  the  aged,  while  other  observers  consider  mitral 
regurgitation  to  be  the  most  prevalent  one.  Aortic  regurgitation 
is  in  some  cases  a  relative  insufficiency  caused  by  dilatation 
of  the  orifice,  more  often,  however,  the  fault  lies  in  the  valve 
itself. 

Etiology. — Relative  insufficiency  is  due  either  to  a  dilata- 
tion of  the  aorta  or  aortic  aneurysm  just  above  the  valve, 
thereby  stretching  the  aortic  ring,  or  to  dilatation  of  the  left 
ventricle.  In  insufficiency  due  to  valvular  defect  the  cause  is 
either  the  general  cause  of  ageing  and  arteriosclerosis  affecting 
primarily  the  valve,  or  it  may  arise  from  the  extension  of  an 
arteriosclerosis  of  the  aorta  or  from  senile  endocarditis. 

Pathology. — In  relative  insufficiency  the  valve  is  not  affected. 
The  orifice  is  distended,  and  when  the  valve  closes,  the  edges 
do  not  approximate.  When  the  fault  lies  in  the  valve  the 
cusps  thicken,  harden,  contract  and  shrivel  up,  or  they  may 
adhere  to  the  endocardium.  The  left  ventricle  receives  normally 
from  the  auricle  the  quota  which  will  completely  fill  it.  When 
more  blood  enters  the  heart  after  rebounding  from  the  aorta 
the   muscle   fibers   become   stretched   and   the   cavity   dilates. 


AORTIC  REGURGITATION 


307 


As  long  as  the  hypertrophy  is  sufficient  to  compensate  for  the 
disturbed  circulation,  no  further  change  occurs.  When  the 
limit  of  functional  ability  is  reached  and  decompensation  begins, 
dilatation  proceeds  rapidly,  an  insufficient  supply  of  blood 
reaches  the  coronaries  and  myocardial  degeneration  sets  in 
through  impaired  nutrition.  The  cordse  tendinas  shrink  and 
cause  relative  insufficiency  of  the  mitral  valve  while  the  valve 
itself  is  weakened  through  the  extra  strain  placed  upon  it  by 
the  greater  amount  of  blood  in  the  ventricle.  It  also  degenerates 
primarily  from  senile  involution  or  secondarily  from  extension 
of  senile  endocarditis.  This  causes  pulmonary  and  venous 
engorgement  with  the  consequent  train  of  symptoms  described 
in  cardiac  dilatation. 

Symptoms. — There  may  be  no  subjective  symptoms  while 
compensation  is  complete,  though  objective  symptoms  and 
physical  signs  are  manifest.  A  pathognomonic  symptom  is 
the  pulse,  called  Corrigan's  or  water  hammer  pulse.  The 
increased  force  required  to  send  an  excessive  amount  of  blood 
from  the  heart  produces  a  strong,  full  pulse,  but  as  some  of  the 
blood  returns  to  the  ventricle  the  pulse  strength  drops  rapidly 
and  fades  away.  This  characteristic  can  be  brought  out  very 
early  in  the  disease,  if  the  arm  is  lifted  above  the  head,  allowing 
the  force  of  gravity  to  aid  in  the  rapid  emptying  and  collapse 
of  the  radial  artery.  Other  early  symptoms  are  increase  in 
carotid  pulsation  and  the  usual  symptoms  of  cardiac  hyper- 
trophy. When  decomposition  sets  in  there  are  the  symptoms 
of  cardiac  dilatation,  with  dyspnea,  precordial  distress,  and  the 
symptoms  of  venous  engorgement. 

The  earliest  physical  sign  is  usually  a  visible  carotid  pulsa- 
tion. The  heaving  impulse  given  to  the  chest  is  not  as  marked 
in  aged  individuals  as  in  earlier  life  owing  to  the  rigidity  of  the 
chest  wall,  but  there  may  be  a  pronounced  bulging.  The  apex 
beat  may  be  weaker  and  more  diffused.  Capillary  pulsation 
is  usually  an  early  sign  and  may  be  demonstrated  by  rubbing 
the  thumb  nail  across  the  forehead,  when  the  hyperemic  line 
will  redden  and  then  become  paler  with  each  pulsation.  Per- 
cussion gives  little  information  of  value,  as  the  heart  is  usually 
hypertrophied  in  the  aged,  but  in  advanced  cases  the  hyper- 
trophy and  consequent  dilatation  are  greater  than  in  any  other 
cardiac  disease. 


308  PATHOLOGICAL    OLD   AGE 

A  diastolic  murmur  in  the  aged  is  virtually  pathognomonic 
of  aortic  regurgitation.  Other  diastolic  murmurs  are  rare  in 
old  people  and  can  readily  be  distinguished  from  the  murmur 
of  aortic  insufficiency.  Pulmonary  regurgitation  which  gives 
a  diastolic  murmur  may  set  in  when  decomposition  is  complete 
and  all  the  valves  are  involved.  By  this  time  the  many  con- 
fusing abnormal  sounds  heard  in  the  chest,  the  diversity  in  the 
areas  and  direction  of  transmission,  the  arrhythmia  and  signs 
of  profound  pulmonary  and  circulatory  disturbances,  make  a 
definite  differential  diagnosis  impossible.  Other  diastolic  mur- 
murs which  might  possibly  occur  in  the  aged  are  a  cardio- 
respiratory murmur  and  a  venous  hum,  due  to  anemia.  The 
former  disappears  when  holding  the  breath,  the  latter  disappears 
when  slight  pressure  is  made  upon  the  jugulars.  (Prolonged 
pressure  may  induce  cerebral  hyperemia  and  hemorrhage.) 
A  diastolic  pericardial  friction  sound  may  be  heard  at  the  base 
of  the  heart  in  acute  adhesive  pericarditis,  but  it  is  incidental 
to  the  pericarditis,  the  sound  is  usually  double  and  the  symp- 
toms of  aortic  disease  are  absent. 

Mitral  stenosis  which  gives  a  presystolic  murmur  may  be 
mistaken  for  aortic  regurgitation.  The  former  immediately 
precedes  the  first  sound,  the  latter  immediately  follows  the 
second  sound.  Mitral  stenosis  is  rare  in  the  aged  except  as  a 
secondary  and  late  sequel  to  aortic  disease,  mitral  regurgitation 
or  general  arteriosclerosis. 

Numerous  other  symptoms  and  signs  may  occur  in  aortic 
regurgitation,  but  they  add  nothing  to  the  determination  of 
the  diagnosis  of  this  disease  in  the  aged.  The  so-called  pistol- 
shot  sound,  a  systolic  sound  heard  over  the  arteries,  especially 
over  the  femoral,  and  caused  by  the  sudden  filling  of  the  empty 
vessel,  is  rarely  appreciable.  Duroziez'  sign,  a  diastolic  mur- 
mur heard  over  the  larger  vessels  when  pressure  is  made  by  the 
stethoscope  is  rarely  heard.  Traube's  sign,  a  double  murmur 
heard  over  the  carotid  and  femoral,  is  rare  and  indistinct.  The 
Flint  murmur,  a  faint  rumble  heard  at  the  apex  immediately 
after  the  murmur  of  the  aortic  regurgitation,  is  occasionally 
met  with,  but  if  occurring  as  a  presystolic  murmur  it  can  hardly 
be  distinguished  from  the  murmur  of  mitral  stenosis  except  by 
the  absence  of  signs  of  pulmonary  engorgement.  The  prognosis 
is  good  as  long  as  the  hypertrophy  maintains  full  compensation. 


AORTIC  STENOSIS 


309 


In  most  cases  the  excessive  work  imposed  upon  the  heart  in 
sending  the  blood  through  sclerosed  vessels  brings  it  sooner  or 
later  to  the  limit  o"  its  functional  ability,  while  the  internal 
pressure  in  the  left  ventricle  produced  by  an  excess  of  blood 
causes  dilatation.  The  mitral  valve  becomes  involved  and  the 
disturbance  in  the  pulmonary  and  circulatory  systems  hasten 
degeneration  of  other  organs.  While  the  mitral  insufficiency 
is  a  temporary  safety  valve  for  the  dilated  ventricle  by  relieving 
the  overdistention,  it  causes  pulmonary  engorgement. 

Dilatation  of  the  aorta  is  generally  associated  with  aortic 
regurgitation,  and  mitral  regurgitation  is  found  in  almost  every 
advanced  case.  This  is  generally  followed  by  mitral  stenosis 
and  aortic  stenosis,  later  by  tricuspid  regurgitation  and  other 
valvular  defects.  The  sequence  may,  however,  be  altered  in 
myocardial  degeneration. 

Treatment. — See  Treatment  of  Cardiac  Lesions. 

AORTIC  STENOSIS 

Aortic  stenosis,  though  occurring  quite  frequently  in  old 
age,  is  always  a  complication  of  some  other  valvular  lesion, 
generally  aortic  regurgitation.  Cabot  reports  that  out  of  over 
250  autopsies  in  cases  of  valvular  disease  there  was  not  a  single 
uncomplicated  aortic  stenosis  but  there  were  29  occurring  with 
aortic  regurgitation. 

Etiology. — This  disease  in  advanced  age  is  due  to  extension 
of  atheroma  from  the  aorta,  extension  of  senile  endocarditis,  or 
atheromatous  deposits  about  the  aortic  ring,  or  it  may  occur  as  a 
degeneration  originating  in  the  valve  itself. 

Pathology. — The  cusps  become  thick  and  rigid  and  some- 
times calcareous  plates  form  under  the  valve,  which  becomes 
misshapen  and  obstructs  the  free  passage  of  the  blood  out  of  the 
ventricle,  while  the  cusps,  not  closing  completely,  allow  blood 
to  return  from  the  aorta,  thus  causing  an  insufficiency.  This 
is  the  usual  condition  of  the  aortic  valve  when  diseased.  In 
some  cases  the  margins  of  the  cusps  adhere  to  each  other,  thus 
reducing  the  opening.  Occasionally  there  are  fibrin  deposits 
upon  the  valves  which  prevent  the  complete  opening  of  the 
cusps,  or  which  present  rough  edges  or  free  ends  to  the  stream. 
Hypertrophy  is  invariably  present  and  late  in  the  disease  there 
is  dilatation. 


3io 


PATHOLOGICAL    OLD    AGE 


Symptoms. — The  pathognomonic  symptom  of  aortic  stenosis 
is  the  pulse,  "pulsus  rarus,  parvus  tardus,"  infrequent,  small  and 
slow,  in  contrast  to  a  strong  apex  beat.  There  is  a  systolic 
murmur,  heard  best  in  the  third  intercostal  space  close  to  the 
right  margin  of  the  sternum,  the  sound  being  carried  upward 
toward  the  neck.  If  a  murmur  is  heard  at  the  apex  also  it  is 
due  to  another  valvular  lesion.  The  area  of  cardiac  impulse  is 
increased,  but  the  apex  impulse  is  indistinct,  the  force  of  the 
heart  is  increased  also,  and  a  purring  thrill  is  felt  over  the 
heart,  especially  marked  over  the  valve,  and  sometimes  felt 
in  the  carotids,  and  there  is  an  increased  area  of  dulness 
to  the  left  and  downward  showing  hypertrophy  of  the  left 
ventricle. 

Other  conditions,  which  give  a  similar  thrill  and  murmur, 
are  aortic  aneurysm  and  aneurysm  of  the  innominata,  and 
these  can  readily  be  differentiated  by  the  absence  of  the  diastolic 
shock,  tumor,  abnormal  pulsation,  pain,  symptoms  of  pressure 
upon  the  trachea,  bronchi  or  recurrent  laryngeal  nerve,  etc., 
found  in  aneurysm,  and  by  the  presence  of  the  characteristic 
pulse.  A  diffuse  dilatation  of  the  aorta  may  give  a  systolic 
murmur,  but  this  condition  is  almost  always  associated  with 
aortic  regurgitation  and  an  increased  area  of  dulness  above  the 
base.  Roughening  of  the  aortic  valve  may  give  a  systolic 
murmur  over  the  valve.  This  is  distinguished  from  the  mur- 
mur of  stenosis  by  the  accentuation  of  the  second  sound  of  the 
heart,  while  in  stenosis  this  sound  is  faint.  If  the  intima  of  the 
aorta  is  roughened  there  may  be  a  systolic  murmur  at  the  base, 
but  there  is  no  thrill  and  the  characteristic  pulse  is  absent. 
Functional  systolic  murmurs  are  rare  in  the  aged  and  they  do 
not  present  any  of  the  other  signs  of  aortic  disease.  Pulmonary 
stenosis  occurs  only  when  all  the  valves  are  involved  in  decom- 
pensation. The  distinguishing  signs  between  aortic  and  pul- 
monary stenosis  are  useless  in  the  aged,  as  the  latter  never  occurs 
without  the  aortic  and  other  cardiac  lesions. 

Mitral  regurgitation  has  a  systolic  murmur  which  is  heard 
most  distinctly  over  the  apex,  but  there  is  no  thrill  nor  the 
characteristic  weak  slow  pulse.  Tricuspid  regurgitation  has  a 
systolic  murmur  but  none  of  the  other  signs  of  aortic  stenosis 
and  there  is  generally  a  jugular  pulsation  and  pulmonary  dis- 
turbance.    Aortic  stenosis  is  almost  invariably  associated  with 


MITRAL  REGURGITATION  311 

aortic  insufficiency  and  the  prognosis  depends  upon  the  prog- 
nosis of  the  latter  disease. 

For  Treatment  see  Cardiac  Lesions. 

MITRAL  REGURGITATION 

Mitral  regurgitation  is  generally  either  a  degenerative  con- 
dition, or  it  is  a  relative  insufficiency  secondary  to  dilatation. 
In  many  cases  both  conditions  prevail. 

Etiology. — Relative  insufficiency  occurs  when  myocarditis 
or  dilatation  stretches  the  orifice  so  that  the  flaps  cannot  ap- 
proximate fully.  This  generally  occurs  after  aortic  regurgita- 
tion and  this  combination  of  valvular  lesions,  aortic  and  mitral 
regurgitation,  is  the  first  result  of  decompensation  following 
the  primary  lesion.  In  rare  cases  the  senile  degenerative 
process  begins  in  the  valve,  more  often  it  follows  an  extension 
of  senile  endocarditis  or  shortening  of  the  cordae  tendinae.  The 
etiological  factors  which  make  it  the  most  prevalent  lesion  in 
earlier  life,  rheumatism  and  excessive  physical  activity,  rarely 
appear  in  later  life. 

Pathology. — The  valve  becomes  thickened,  hardened  and 
shortened.  The  cordae  tendinae  thicken  and  shorten  and  drag 
down  the  flaps.  The  papillary  muscles  grow  thinner.  The 
valve  flaps  may  adhere  to  the  ventricular  wall  and  thus  become 
immobilized.  The  excess  of  blood  in  the  auricular  chamber 
causes  the  walls  of  that  chamber  to  dilate.  The  walls  at  the 
same  time  hypertrophy  and  for  a  time  compensation  is  main- 
tained, but  the  dilatation  proceeds  faster  than  the  hypertrophy 
and  the  latter  soon  reaches  the  limit  of  its  capacity.  After 
decompensation  sets  in,  the  blood  is  dammed  back  into  the 
lungs  and  later  the  right  side  of  the  heart  becomes  affected. 
There  is  first  hypertrophy,  later,  dilatation  of  the  right  ventricle, 
tricuspid  regurgitation,  right  auricular  hypertrophy,  then  dila- 
tation, obstruction  to  the  venous  circulation,  with  degenera- 
tion following  passive  congestion  of  the  liver,  kidneys,  stomach, 
spleen,  etc.  Late  in  the  disease,  hypertrophy,  then  dilatation 
of  the  left  ventricle  occurs,  and  every  valve  and  chamber  of  the 
heart  is  affected. 

Symptoms. — There  are  no  early  symptoms  or  signs  of  mitral 
regurgitation  except  a  systolic  murmur  at  the  apex,  the  sound 


-jI2  PATHOLOGICAL   OLD    AGE 

being  carried  to  the  back  behind  or  below  the  angle  of  the  scap- 
ula.    The  apex  beat  is  found  more  to  the  left  than  normal  and 
the  area  of  dulness  is  increased  downward  and  to  the  left.     The 
second  sound  of  the  heart  is  more  intense  over  the  pulmonic 
valve.     When    dilatation   and    decompensation    ensues,    there 
follows  the  train  of  symptoms  described  under  cardiac  dilata- 
tion.    The    earliest    of    these    symptoms    is    cardiac    asthma, 
dyspnea,   palpitation  and   slight   cyanosis  upon  exertion,  and 
sometimes    even    without    exertion.     Later    the    dyspnea    and 
cyanosis  are  constant  and  venous  engorgement  of  the  liver, 
kidneys,   brain  and  stomach  follow.     The  disturbance  to  the 
pulmonary  circulation  produces  dyspnea,  cyanosis  and  a  cough 
with    watery    and    occasionally    blood-stained    expectoration. 
The  liver  becomes  enlarged,  there  is  a  feeling  of  weight  and  pain 
in  the  right  hypochondrium  and  there  may  be  jaundice.     Kidney 
involvement  is  shown  in  scanty  high-colored  urine,  sometimes 
albuminous  and  occasionally  presenting  casts.     Cerebral  hyper- 
emia  is   produced   with   headache,  vertigo,   occasional  stupor 
or  even  delirium.     There  is  gastric  and  intestinal  catarrh  and 
usually   hemorrhoids.     Later,    as    a   result   of   the   circulatory 
disturbance,  dropsy  and  anasarca  set  in.     The  pulse  becomes 
weak  and,  upon  excitement,  it  is  irregular  in  rhythm  and  force. 
Diagnosis. — The  only  other  systolic  murmurs  that  may  be 
confused  with  that  of  mitral  regurgitation  are  functional  mur- 
murs and  the  murmur  of  tricuspid  regurgitation.     Functional 
murmurs  are  rare  in  the  aged,  they  are  faint  or  absent  while 
in  the  upright  position  and  are  transmitted  to  the  back.     The 
murmurs  of  aortic  stenosis  and  roughening  of  the  aortic  valve 
are  heard  best  over  the  valve  and  are  not  transmitted  to  the 
back.     Aortic    stenosis    has    a    characteristic    pulse    which    is 
absent  in  the  mitral  disease. 

Tricuspid  regurgitation  gives  a  murmur  so  similar  to  that 
of  mitral  regurgitation  that  it  is  often  impossible  to  differen- 
tiate between  them  and  as  the  tricuspid  lesion  always  occurs 
after  the  mitral  lesion  it  is  generally  overlooked.  Tricuspid 
murmurs  are  not  heard  in  the  back  and  their  maximum  in- 
tensity is  to  the  right  of  the  sternum,  but  they  may  be  heard 
distinctly  at  the  apex.  These  points  are,  however,  useless 
for  the  determination  of  the  diagnosis,  as  the  mitral  lesion  is 
invariably  present.     Jugular  pulsation,  an  early  symptom  of 


MITRAL  STENOSIS 


3*3 


tricuspid  regurgitation,  does  not  occur  in  uncomplicated  mitral 
regurgitation.  If  it  does  appear  in  mitral  disease  it  is  an 
evidence  of  tricuspid  involvement. 

Treatment  is  given  under  Cardiac  Lesions. 

MITRAL  STENOSIS 

Mitral  stenosis  is  a  degenerative  process  in  which  the 
shrunken  and  thickened  flaps  diminish  the  size  of  the  auriculo- 
ventricular  opening. 

Etiology. — The  causes  prevailing  in  earlier  life  do  not  prevail 
in  old  age  and  when  the  disease  occurs  in  earlier  life  the  in- 
dividual does  not  live  long  enough  to  grow  old.  Mitral  stenosis, 
when  occurring  in  the  aged,  is  almost  always  due  to  a  degenera- 
tive process  originating  in  the  valve  itself  or  carried  to  the 
flaps  by  extension  from  senile  endocarditis.  It  may  follow 
Blight's  disease  and  Vinay  reported  a  case  in  which  a  deposit 
of  calcareous  matter  about  the  ring  caused  a  diminution  in 
the  size  of  the  orifice. 

Pathology. — The  flaps  become  thickened,  hardened  and 
shrunken.  The  shrinking  of  the  valves  prevents  complete 
apposition  of  the  edges  with  consequent  mitral  insufficiency. 
The  button-hole  slit  caused  by  adhesion  of  the  edges  of  the  valve 
is  rarely  found  in  advanced  life.  This  adhesion  may  be  due 
either  to  a  change  in  the  blood  which  permits  fibrin  to  be 
deposited  upon  the  edges  with  consequent  agglutination  of 
these  deposits,  or  else  to  an  irritation  with  following  adhesive 
inflammation  of  the  edges,  from  blood  toxins.  The  latter 
cause  would  also  explain  the  presence  of  endocarditis  wher- 
ever we  find  the  button-hole  slit.  The  only  disease  causing 
such  irritation  in  old  age  is  chronic  nephritis  and  it  is  only 
when  this  disease  is  present  that  the  button-hole  slit  is  found. 
When  the  stenosis  progresses  and  mitral  regurgitation  ensues, 
there  follow  hypertrophy  and  dilatation  of  the  left  auricle, 
with  blocking  of  the  pulmonary  circulation  and  with  the  train 
of  disorders  that  follow  pulmonary  engorgement. 

Symptoms. — Mitral  stenosis  is  a  lesion  that  may  exist  for 
years  without  giving  any  marked  symptoms  or  signs.  Among 
the  earliest  of  the  suggestive  symptoms  is  irregularity  of  the 
heart  in  rhythm  and  force  upon  exertion  which  rapidly  subsides 


3J4 


PATHOLOGICAL   OLD   AGE 


after  resting.  Occasionally  a  purring  thrill  may  be  felt  at  the 
apex  just  preceding  the  apex  beat.  As  the  disease  is  almost 
invariably  associated  with  mitral  insufficiency,  the  symptoms  of 
stenosis  may  be  completely  masked  by  those  of  the  insufficiency 
and  as  soon  as  decompensation  sets  in  there  are  the  usual 
symptoms  of  pulmonary,  and  later,  venous  engorgement.  The 
only  symptom  pointing  to  mitral  stenosis  is  frequent  hemop- 
tysis. The  murmur  of  mitral  stenosis  is  almost  pathognomo- 
nic. It  is  a  presystolic  murmur,  loud,  long  and  rumbling,  end- 
ing with  the  first  sound  of  the  heart,  and  heard  in  a  limited 
area  about  the  apex.  The  only  other  murmur  which  may 
possibly  be  mistaken  for  it  is  the  Flint  murmur,  which  occurs 
occasionally  in  aortic  regurgitation  and  tricuspid  stenosis,  a 
very  rare  condition,  unknown  in  the  aged. 

The  murmur  of  mitral  stenosis  is  frequently  absent  in  the 
early  stage  of  the  disease  or  it  may  appear  temporarily  dur- 
ing or  immediately  following  exertion.  It  also  disappears  after 
decompensation  sets  in.  The  purring  thrill  about  the  apex  can 
sometimes  be  felt  before  the  murmur  appears  and  it,  too,  dis- 
appears as  soon  as  decompensation  occurs.  It  is  presystolic, 
and  ends  with  the  apex  beat. 

The  first  sound  of  the  heart  is  short,  loud  and  snapping; 
the  pulmonic  second  sound  is  accentuated  and  is  sometimes 
double.  When  decompensation  occurs  or  when  other  valvular 
lesions  exist,  the  short,  sharp  first  sound  may  be  the  only  sign 
determining  the  presence  of  a  mitral  stenosis. 

The  prognosis  of  mitral  stenosis  in  the  aged  depends  upon 
the  mitral  regurgitation  present.  The  two  may  exist  for  years 
without  giving  distress,  but  sooner  or  later  decompensation 
sets  in  and  carries  the  patient  rapidly  to  the  fatal  issue. 

Treatment. — See  Treatment  of  Cardiac  Lesions. 

TRICUSPID  REGURGITATION 

Tricuspid  insufficiency,  though  rarely  diagnosed,  is  a  fre- 
quent sequel  to  mitral  disease  in  the  aged.  In  these  cases  it  is 
a  relative  insufficiency,  caused  by  a  dilatation  of  the  right  ven- 
tricle with  stretching  of  the  auriculo-ventricular  orifice.  A 
degeneration  of  the  valve  is  possible,  but  out  of  over  400  au- 
topsies made  in  Guy's  Hospital  in  which  tricuspid  insufficiency 


COMBINED  VALVULAR  LESIONS 


315 


was  found,  there  was  not  one  showing  valvular  degeneration. 
In  some  cases  it  was  due  to  myocarditis  or  to  pulmonary  disease. 

Symptoms. — The  symptoms  are  referable  to  venous  engorge- 
ment. Specially  marked  in  this  disease  are  systolic  jugular 
pulsation  or  vibration,  distention  of  the  superficial  veins  of  the 
upper  part  of  the  body  when  the  patient  coughs  or  strains,  and 
cyanosis  which  is  more  pronounced  when  the  patient  is  in  the 
horizontal  position.  When  in  this  position  cerebral  hyperemia 
occurs  and  may  be  of  such  extent  as  to  produce  cerebral  com- 
pression with  stupor  and  coma.  Symptoms  associated  with 
passive  congestion  in  other  organs  appear,  especially  in  the 
liver  and  kidneys.  A  pulsation  over  the  liver  is  pathognomonic 
of  tricuspid  regurgitation,  but  it  is  often  absent.  A  jugular 
pulsation  or  vibration  may  be  normal  or  due  to  other  causes. 
If  a  vein,  after  being  temporarily  emptied  by  stroking  from 
below  upward,  immediately  fills  up  from  below,  it  is  pathogno- 
monic of  tricuspid  regurgitation.  If  it  does  not  fill  from  below, 
the  cause  of  the  pulsation  is  not  due  to  this  disease.  Tricuspid 
regurgitation  presents  definite  physical  signs  but  in  the  aged 
this  condition  is  almost  invariably  associated  with  mitral 
regurgitation  and  the  more  marked  signs  of  the  mitral  disease 
may  mask  the  signs  of  the  tricuspid  lesion.  There  is  a  systolic 
murmur  near  the  fifth  left  costal  cartilage,  not  loud,  and  often 
absent.  In  some  cases  it  may  be  brought  out  in  Stern's  posi- 
tion, i.e.,  the  patient  lying  horizontally  with  the  head  slightly 
lowered.  The  area  of  dulness  is  increased  to  the  right  of  the 
sternum. 

The  diagnosis,  in  the  absence  of  the  murmur,  depends  upon 
the  pulmonary  symptoms,  dyspnea  and  cyanosis  which  become 
worse  in  a  horizontal  position.  Jugular  and  epigastric  pulsa- 
tion confirm  the  diagnosis. 

Treatment. — See  Treatment  of  Cardiac  Lesions. 

COMBINED  VALVULAR  LESIONS 

It  frequently  happens  that  two  or  more  valvular  lesions 
exist  at  the  same  time.  One  valvular  lesion  may  cause  a  defect 
in  another,  or  the  same  valve  may  produce  both  stenosis  and 
regurgitation.  Such  combined  valvular  lesions  produce  a 
variety  of  symptoms  and  signs,  some  of  which  may  modify 
others. 


316  PATHOLOGICAL    OLD    AGE 

The  most  frequent  of  the  combined  lesions  is  aortic  regurgi- 
tation and  a  relative  mitral  insufficiency  produced  by  the  ven- 
tricular dilatation  following  the  aortic  defect.  Tricuspid  rela- 
tive insufficiency  follows  a  mitral  regurgitation.  If  there  is  a 
mitral  stenosis,  a  mitral  regurgitation  accompanies  it.  Aortic 
stenosis  is  generally  associated  with  aortic  regurgitation  or  is 
followed  by  mitral  regurgitation.  When  compensation  is  lost 
there  may  be  aortic,  mitral  and  tricuspid  lesions  with  murmurs 
all  over  the  chest,  and  arrhythmia,  irregular  pulse  and  irregular 
cardiac  impulse,  making  it  impossible  to  determine  what  valves 
are  affected  or  how. 

In  aortic  and  mitral  regurgitation  a  murmur  is  heard  after 
each  sound,  the  murmur  after  the  first  sound  being  most  distinct 
at  the.  apex,  the  diastolic  murmur  being  loudest  at  the  third 
costo-sternal  articulation.  The  murmurs  are  transmitted  down- 
ward and  to  the  left.  The  water  hammer  pulse  is  modified;  it 
is  weaker  and  does  not  fade  away  as  rapidly  as  in  the  uncom- 
plicated aortic  regurgitation.  Capillary  pulse  may  be  absent. 
In  aortic  stenosis  and  regurgitation  there  is  a  double  murmur 
over  the  aortic  area,  one  after  the  first  sound,  the  other  one  fol- 
lowing the  second  sound  of  the  heart,  the  first  being  transmitted 
upward  toward  the  neck,  the  other  downward  toward  the 
xiphoid  cartilage.  The  pulse  is  modified  as  in  mitral  complica- 
tion, capillary  pulsation  is  diminished  and  the  pulsation  in  the 
peripheral  vessels  may  be  absent.  The  thrill  of  aortic  stenosis 
may  be  absent  also. 

In  double  mitral  disease  the  murmur  precedes  and  follows 
the  first  sound  of  the  heart.  The  presystolic  murmur  is  often 
absent  and  must  be  brought  out  by  some  exertion  such  as  a 
fast  walk  or  jump.  If  once  heard  the  diagnosis  is  certain  and  as 
mitral  obstruction  is  always  associated  with  regurgitation,  the 
symptoms  of  the  latter  disease  need  not  be  sought  for. 

Mitral  obstruction  does  not  occur  with  aortic  disease.  Aor- 
tic stenosis  may  be  associated  with  mitral  regurgitation.  There 
is  a  systolic  hour-glass  murmur  in  this  case,  the  one  maxi- 
mal point  being  at  the  apex,  the  other  at  the  second  right 
costo-sternal  articulation  or  just  below  it  with  a  vanishing  point 
at  the  fourth  left  costo-sternal  articulation.  The  pulse  of  aor- 
tic stenosis  is  not  altered,  but  the  thrill  is  weakened. 

Mitral   regurgitation   and   tricuspid   regurgitation   are   often 


TREATMENT  OF  CARDIAC  LESIONS  317 

found  together  but  it  is  necessary  to  determine  the  presence  of 
the  tricuspid  lesion  alone.  The  murmurs  of  the  two  occur  at 
the  same  time  their  areas  of  conductivity  overlap  and  their 
points  of  maximum  intensity  are  so  close  together  that  errors 
are  very  liable  to  occur.  The  diagnosis  must  be  made  by  the 
signs  of  mitral  regurgitation  and  by  the  symptoms  of  the  tri- 
cuspid disease,  like  jugular  pulsation,  etc. 

TREATMENT  OF  CARDIAC  LESIONS 

In  the  treatment  of  cardiac  lesions  in  old  age  this  rule  is 
imperative:  No  interference  while  compensation  is  complete. 
Proper  hygiene  and  the  avoidance  of  sudden  or  prolonged 
strain  must  be  observed  to  prevent  rapid  loss  of  muscle  tone, 
and  there  should  be  no  medicinal  treatment  as  long  as  the 
heart  maintains  its  strengh  and  regularity. 

The  aged  person  should  continue  to  take  exercise  and  may 
continue  at  his  ordinary  vocation  if  it  does  not  involve  sudden 
strains,  but  the  moment  dyspnea  or  palpitation  appears  he 
must  stop  and  lie  down.  He  must  guard  against  straining  at 
stool  and  should  avoid  foods  which  tend  to  produce  flatulency. 
Intense  mental  concentration  and  powerful  emotions,  even  if 
pleasurable,  are  injurious,  while  shock  may  cause  sudden  death. 

Failing  compensation  comes  on  gradually  and  its  earliest 
symptom  is  slight  dyspnea  without  previous  exertion.  As  soon 
as  this  is  noticed  the  patient  should  go  to  bed  and  remain  there 
for  at  least  a  week.  Compensation  is  occasionally  restored  by 
prolonged  absolute  rest.  In  administering  drugs  in  cardiac 
disease  of  the  aged,  there  are  a  few  general  rules  that  must  be 
observed.  Heart  tonics  should  not  be  given  until  they  are 
required  to  overcome  weakness,  and  heart  stimulants  should 
never  be  given  except  in  an  emergency  or  to  counteract  rapidly 
acting  cardiac  depressants.  Vasoconstrictors  must  be  used 
cautiously,  as  the  sclerosed  vessels  may  not  be  able  to  with- 
stand increased  pressure.  Heart  depressants  are  of  service 
only  in  hypertrophy  without  valvular  lesion.  Drugs  are  rarely 
required  in  this  condition  unless  the  hypertrophy  is  extensive 
enough  to  cause  palpitation  and  active  cerebral  congestion. 
In  this  case  we  can  use  aconite  in  i -minim  doses  several  times  a 
day  until  the  heart  action  is  lowered.     Veratrum  viride  or  gel- 


318  PATHOLOGICAL    OLD    AGE 

seminum  in  5 -minim  doses  of  the  tincture  can  be  given  in  the 
place  of  aconite.  (Chloral  hydrate  should  not  be  used  in  old 
age.)  In  some  cases  of  aortic  stenosis  aconite  or  veratrum  will 
steady  the  heart  but  the  drug  must  be  stopped  as  soon  as  an 
effect  is  produced.  Digitalis,  the  most  valuable  drug  in  the 
pharmacopeia,  is  dangerous  in  senile  conditions.  It  is  contra- 
indicated  in  aortic  disease,  myocardial  degeneration  and  in  cases 
of  high  blood  pressure.  When  given  by  mouth  the  response  in  a 
stronger  pulse  appears  about  twelve  to  thirty-six  hours  later; 
therefore,  it  is  useless  when  quick  action  is  desired.  It  must  be 
noted  that  its  action  is  cumulative.  The  author  has  seen  two 
cases  of  apoplexy  following  the  hypodermic  use  of  digitalis 
preparations  in  threatened  heart  failure.  If  the  heart  is  rapid 
and  weak  tincture  of  strophanthus  should  be  given  in  2-  to  4- 
minim  doses.  Adonin  in  1/8-grain  doses  several  times  daily 
can  be  used  in  aortic  regurgitation.  Tincture  of  cactus  grandi- 
florus  in  5 -minim  doses  and  of  convallaria  5-  to  10-minim  doses 
can  be  given  in  place  of  digitalis  and  strophanthus.  The  fre- 
quent lack  of  success  when  using  these  drugs  must  be  ascribed 
to  their  poor  quality.  More  positive  results  are  obtained  when 
using  their  glucosides,  convallamarin  and  cactin.  The  special 
indication  for  spartein  is  a  slow,  weak  heart,  such  as  occurs  in 
decompensation  following  aortic  stenosis.  This  should  be  used 
in  1/2-  to  2 -grain  doses  until  the  heart  beats  respond  with 
greater  strength  and  frequency,  when  it  must  be  discontinued. 
It  may  be  combined  with  1/50-grain  strychnia.  The  nitrites, 
amyl  nitrite,  spirit  glonoin  and  sodium  nitrite  are  powerful 
vasodilators  and  should  be  used  only  to  relieve  cardiac  spasm, 
an  overdistended  heart  or  poor  peripheral  circulation.  They 
should  not  be  used  if  the  face  is  flushed  or  where  there  is  cerebral 
hyperemia.  The  amyl  nitrite  used  in  3-  to  5 -minim  doses  by 
inhalation  is  of  service  in  angina  pectoris,  cardiac  asthma  and 
syncope.  In  threatened  heart  failure  nitroglycerin  in  1/100- 
grain  dose  can  be  used  hypodermically  combined  with  1/30- 
grain  strychnine  and  1/100  grain  digitalin.  For  prolonged  ac- 
tion the  nitrite  of  soda  can  be  given  in  1/6-  to  1 -grain  doses 
every  four  hours. 

Other  emergency  drugs  are  to  be  given  only  where  there  is 
danger  of  cardiac  exhaustion;  these  are  carbonate  of  ammonia 
in  5_grain  doses,  compound  spirits  of  ether  30  minims,  or  sul- 


TREATMENT  OF  CARDIAC  LESIONS  319 

phuric  ether  hypodermically  in  20-minim  doses,  camphor  5 
grains  in  oily  solution  hypodermically,  and  alcohol.  The  most 
rapid  action  is  obtained  from  the  hypodermic  use  of  ether  but 
the  action  is  evanescent.  Strychnine  should  not  be  used  before 
decompensation  sets  in,  as  it  simply  hastens  decompensation 
and  it  should  be  used  only  as  an  emergency  drug,  being  a  cardiac 
stimulant  and  not  a  cardiac  tonic.  The  distressing  symptoms 
accompanying  cardiac  lesions  require  treatment  distinct  from 
that  of  the  disease. 

For  dyspnea,  if  there  is  no  contraindication  to  the  nitrites, 
the  nitrite  of  amyl  gives  most  prompt  relief.  Morphine  or 
dionin  in  1/8-grain  doses  is  of  service  for  dyspnea  occurring  at 
night  and  preventing  sleep.  However,  neither  the  nitrites  nor 
morphine  should  be  used  continuously.  For  prolonged  treat- 
ment the  tincture  of  cimicifuga  in  i-dram  doses,  combined  with 
arsenic  in  the  form  of  Fowler's  solution  in  doses  of  3 -minims, 
should  be  used  three  times  a  day.  The  arsenic  must  be  discon- 
tinued when  its  physiological  symptoms  appear. 

Cardiac  asthma  will  generally  yield  to  1/2-dram  doses  of 
compound  spirits  of  ether.  Palpitation  or  arrhythmia  will 
sometimes  subside  upon  a  hypodermic  injection  of  1/120  grain 
of  atropia.  If  it  occurs  frequently  the  bromides  may  be  given. 
The  selection  of  the  drug  must  depend  upon  the  condition  of 
the  heart,  using  sedatives  in  hypertrophy,  the  nitrites  if  there  is 
high  blood  pressure,  and  morphine,  spartein,  strychnine,  ice- 
bags,  etc.,  as  indicated.  In  some  cases  when  decompensation 
sets  in  suddenly  with  dyspnea  and  palpitation,  immediate  rest 
in  bed,  remaining  there  for  several  days  while  eating  and  drink- 
ing sparingly,  will  restore  compensation. 

In  insomnia  a  hot  foot  bath  should  be  tried.  If  this  fails  we 
can  use  5  to  10  grains  of  veronal  and  if  there  is  considerable 
mental  agitation  it  should  be  combined  with  3  grains  of  mono- 
bromated camphor.  No  Chloral!  Morphia  may  be  used  if 
veronal  fails,  but  it  must  be  combined  with  atropin  to  prevent 
paralysis  of  the  respiratory  centers. 

Nothing  will  relieve  the  cyanosis  except  the  inhalation  of 
oxygen  and  this  is  of  service  only  while  it  is  being  used.  It 
should  be  employed  occasionally  in  cyanotic  cases  to  improve 
the  condition  of  the  blood,  and  to  give  temporary  relief  to  the 
lungs  and  thus  indirectly  to  the  brain.     Edema,  which  occurs 


320 


PATHOLOGICAL    OLD   AGE 


late,  unless  associated  with  nephritis,  is  difficult  to  treat  in 
the  aged.  A  salt-free  diet  is  the  most  important  measure. 
For  this  purpose  malted  milk  with  milk  or  water  in  small  quan- 
tities, just  sufficient  to  supply  the  actual  needs  of  the  system, 
should  be  taken.  Mild  diuretics  should  be  used.  In  cardiac 
dropsy  calomel  in  i/io-grain  doses  every  three  hours  and  4 
drams  potassium  bitartrate  every  second  day  will  produce  free 
diuresis  and  catharsis.  The  legs  should  be  elevated  and  when 
the  edema  disappears  they  should  be  bandaged,  but  the  band- 
ages must  not  be  too  tight,  as  they  might  compress  sclerosed 
vessels  and  obliterate  them.  Puncturing  the  edematous  limbs  is 
useless  in  the  dropsy  due  to  tricuspid  regurgitation  as  edema 
reappears  in  a  few  days,  but  it  may  become  necessary  to  punc- 
ture an  abdominal  dropsy.  If  chronic  nephritis  complicates 
the  cardiac  disease  diuretics  should  be  used  cautiously,  lest  they 
increase  the  irritation  to  the  kidney.  It  is  better  in  these  cases 
to  try  to  reduce  the  edema  by  a  salt-free  diet  and  hydragogue 
cathartics,  though  the  latter  further  impair  the  already  im- 
poverished blood. 

The  Oertel,  Schott,  and  Nauheim  treatments  of  heart 
disease  are  contraindicated  in  old  persons. 

INTESTINAL  OBSTRUCTION 

Partial  obstruction  is  generally  overlooked.  It  may  be  tem- 
porary or  permanent,  coming  on  slowly,  and  gradually  increas- 
ing until  complete  occlusion  occurs,  or  it  may  come  on  rapidly 
and,  if  due  to  impaction,  is  quickly  relieved  by  removal  of  the 
offending  substance.  Complete  occlusion  comes  on  suddenly 
and  unless  soon  relieved  is  rapidly  fatal.  The  two  conditions, 
stenosis  and  occlusion,  will  be  described  separately. 

Intestinal  Stenosis 

Etiology. — The  most  frequent  cause  of  temporary  stenosis 
in  later  life  is  impaction  with  feces  or  gall-stones,  while  a  per- 
manent stenosis  is  usually  due  to  enteroptosis.  Other  causes  are 
partial  occlusion  by  growths  within  the  bowel,  or  pressure 
from  adjacent  tissues  upon  the  bowel;  thickening  due  to  in- 
flammation; contraction  following  such  inflammation;  contrac- 


INTESTINAL  STENOSIS  3  21 

tion  or  growth  of  scar  tissue  over  the  site  of  an  ulcer,  or  other 
lesion;  kinks,  volvulus,  hernial  constrictions,  strangulation  by- 
bands,  adhesions  to  the  peritoneum  or  mesentery,  etc.  Intus- 
susception is  rare  in  the  aged.  Many  of  these  causes  may 
produce  complete  occlusion.  Obstruction  of  the  bowel  may 
also  be  due  to  primary  intestinal  paresis  or  it  may  be  due  to  a 
hemiplegia  or  paraplegia,  the  paralysis  producing  a  paralysis  of 
the  intestines  with  consequent  intestinal  impaction. 

Symptoms. — The  symptoms  of  intestinal  obstruction  depend 
upon  the  cause,  degree  and  location  of  the  obstruction.  Com- 
plete obstruction  will  be  considered  in  the  chapter  on  Intestinal 
Occlusion. 

The  location  of  the  obstruction  can  often  be  determined 
by  inspection  and  palpation,  occasionally  by  other  signs.  If 
the  duodenum  or  jejunum  is  blocked,  the  upper  part  of  the 
abdomen  is  distended,  digestive  disorders  occur  early,  vomiting 
may  occur  but  it  has  no  fecal  odor.  The  urine  is  diminished  or 
may  be  entirely  suppressed.  If  obstructed  in  the  region  of  the 
ileocecal  valve  the  distention  is  greatest  about  the  umbilicus 
and  there  is  early  fecal  vomiting,  or,  if  the  obstruction  is  not 
severe  or  complete,  there  may  be  eructations  of  gas  having  a 
fecal  odor.  Peristaltic  movements  are  often  observable  over 
the  upper  part  of  the  abdomen.  If  the  obstruction  is  in  the 
large  intestine  the  distention  is  at  the  sides  and  lower  part  of 
the  abdomen.  Obstruction  due  to  impaction  of  feces  or  other 
substances,  or  to  growths,  can  generally  be  diagnosed  by  the 
presence  of  a  mass  at  the  point  of  obstruction.  A  doughy  mass 
which  pits  upon  pressure  and  remains  pitted  is  feces;  a  hard 
mass  may  be  gall-stones  or  enteroliths ;  a  soft  mass  which  does 
not  pit  is  a  growth.  There  may  be  impaction  above  a  growth 
and  the  palpation  signs  of  both  will  manifest  themselves.  An 
intestinal  growth  is  movable  with  the  bowel.  If  outside  of  the 
intestines  it  can  be  separated  from  the  bowel.  Complete 
occlusion  of  the  large  intestine  can  be  determined  by  testing 
the  capacity  of  that  portion  of  the  gut.  The  rectum  holds 
normally  three  pints,  the  colon  holds  six  quarts  of  water.  If 
the  entire  amount  can  be  introduced  the  obstruction  is  above 
the  colon. 

Enter optosis  is  frequently  found  in  the  aged  in  connection 
with  ptoses  of  other  abdominal  viscera.     It  is  due  to  weakened 

21 


322 


PATHOLOGICAL   OLD    AGE 


mesenteric  attachment,  flaccid  abdominal  walls,  the  weight  of 
other  displaced  viscera,  and  possibly,  to  the  weight  of  feces  in 
the  transverse  colon.  There  are  no  clearly  defined  symptoms, 
and  a  positive  diagnosis  can  be  made  only  by  radiography. 
The  presence  of  a  gastroptosis  which  can  often  be  diagnosed 
by  percussion  and  sometimes  by  inspection,  associated  with  a 
sense  of  weight  in  the  pelvis  and  with  protrusion  of  the  lower 
part  of  the  abdomen,  point  to  enteroptosis.  There  is  also  usu- 
ally backache,  flatulence  and  frequent  urination.  It  is  sometimes 
possible  to  inflate  the  colon  and  its  location  can  then  be  made 
out  providing  the  abdominal  walls  are  thin.  The  symptoms 
pointing  to  partial  obstruction  in  the  displaced  gut  are  constipa- 
tion, a  powerful  effort  being  required  to  force  the  stool  out, 
occasional  watery  diarrhea  containing  scales  of  hardened  feces 
which  irritate  the  sphincter  ani  and  distention  of  the  bowels 
with  gas  and  gurgling  sounds  in  the  lower  part  of  the  abdomen. 
There  are  often  colicky  pains,  especially  when  making  an 
effort  to  propel  the  feces,  which  are  passed  in  a  ribbon  or  pencil 
form,  depending  upon  the  shape  of  the  stenosed  aperture. 
Impacted  feces  can  sometimes  be  felt  in  the  right  iliac  fossa. 

Impaction  of  feces  generally  occurs  in  the  descending  colon. 
The  mass  can  be  felt  and  distinguished  by  its  doughy  consis- 
tency, the  impress  made  upon  the  mass  by  the  pressure  of  the 
finger  remaining  after  the  pressure  is  removed.  There  are 
colicky  pains  and  tenesmus,  abdominal  distention  by  gas, 
constipation,  stools  occasionally  passing  in  small  scales  and 
irregular  lumps.  In  some  cases  feces  will  force  a  channel 
through  the  impacted  mass  and  will  then  come  away  in  small 
cylinders  or  balls.  It  is  thus  possible  to  have  a  daily  stool  with 
fecal  impaction.  Fecal  impaction  will  give  the  constitutional 
symptoms  of  autointoxication  due  to  the  reabsorption  of  fecal 
matter.  Impaction  by  gall-stones,  enteroliths  and  other  foreign 
bodies  generally  occurs  either  at  the  ileocecal  valve  or  in  the 
upper  part  of  the  bowel.  These  may  sometimes  be  felt  as 
hard  masses,  not  doughy,  if  the  abdominal  walls  are  thin  and 
the  intestines  are  not  distended  with  gas.  They  produce 
considerable  colic  and  digestive  disturbance  but,  unless  they 
completely  occlude  the  gut,  they  allow  the  passage  of  semiliquid 
fecal  matter,  which  reaching  the  lower  bowel  becomes  formed 
and  passes  as  a  normal  stool.     If  due  to  gall-stones  there  will 


INTESTINAL  STENOSIS  323 

be  the  symptoms  pointing  to  them  and  bile  will  be  found  in  the 
stools.  Enteroliths  and  other  foreign  bodies  give  no  distinctive 
signs  by  which  their  nature  can  be  determined.  The  presence 
of  a  mass  which  cannot  be  pressed  into  or  moved  without  drag- 
ging along  adjoining  tissues,  eliciting  a  dull  ache,  but  no  sharp 
pain  upon  pressure,  and  giving  the  other  symptoms  of  intes- 
tinal obstruction  points  to  a  foreign  body  partly  occluding  the 
intestines.  The  X-ray  gives  the  most  definite  information. 
Growths  may  occlude  the  lumen  of  the  bowel  entirely  or  partly. 
Benign  growths  increase  slowly,  the  symptoms  are  mild  and 
may  pass  unrecognized  until  complete  occlusion  occurs.  The 
intestines  may  accustom  themselves  to  the  increased  pressure 
at  the  point  of  constriction  and  a  compensatory  dilatation 
opposite  to  the  growth  may  result.  In  such  cases  the  feces  will 
appear  ribbonlike.  Malignant  growths  occur  most  frequently 
in  the  colon  and  rectum.  They  are  readily  diagnosed  by 
their  rapid  progress,  pain,  cachexia,  emaciation,  involvement 
of  other  tissues,  etc.  Cicatricial  stricture,  and  contractions, 
following  inflammation  cannot  be  specially  diagnosed.  They 
may  be  suspected  where  there  is  a  pencil-shaped  stool  with 
the  usual  symptoms  of  partial  obstruction,  constipation  with 
occasional  stools,  tenesmus,  distention  of  the  bowels,  and 
colicky  pains;  these  symptoms  slowly  increasing  in  severity. 
Adhesions  to  the  peritoneum  or  mesentery  may  occur  and  give 
rise  to  partial  obstruction  of  the  gut  with  the  ordinary  symp- 
toms of  that  condition.  There  are  no  pathognomonic  signs 
and  the  diagnosis  must  be  made  by  the  history  of  a  former 
peritonitis  and  exclusion  of  other  causes.  The  symptoms  are 
usually  mild,  in  some  cases  consisting  only  of  an  irregular 
constipation  and  occasionally  a  feeling  of  dragging  upon  the 
abdominal  walls.  Paresis  of  the  intestines,  if  occurring  suddenly, 
gives  the  symptoms  of  complete  occlusion.  A  slow  progressive 
paresis  begins  with  constipation,  a  gradually  increasing  difficulty 
in  emptying  the  bowels  and  finally  complete  inability  to  move 
them  followed  by  all  the  symptoms  of  complete  occlusion. 
Kinks  described  by  Lane  may  occur  in  any  part  of  the  intestines 
and  produce  a  partial  obstruction  with  chronic  intestinal  stasis. 
This  does  not  give  the  usual  symptoms  of  obstruction,  but  the 
symptoms  of  a  slow  persistent  antointoxication.  It  rarely 
proceeds  to  occlusion.     Strangulation  by  bands,  or  hernial  con- 


324  PATHOLOGICAL   OLD    AGE 

tractions,  volvulus  and  intussusception  almost  always  cause 
complete  occlusion  at  once  or  within  a  few  hours. 

Prognosis. — The  prognosis  of  intestinal  stenosis  depends 
upon  the  cause.  Fecal  impaction  can  generally  be  removed 
and  the  obstruction  disappears.  Enteroptosis  and  adhesions 
to  the  peritoneum  are  permanent.  They  rarely  produce 
much  distress,  rarely  progress  to  complete  occlusion  and  do 
not  endanger  life  unless  complete  occlusion  occurs.  Benign 
growths  and  cicatricial  stricture  proceed  very  slowly  to  com- 
plete occlusion,  while  malignant  growths  rapidly  close  the  gut, 
and  such  growths  outside  of  the  intestine,  but  in  close  juxtaposi- 
tion to  it,  will  frequently  involve  the  bowel.  Obstruction  due 
to  other  causes  generally  proceeds  rapidly  to  complete  occlusion. 

Treatment. — Medicinal  measures  are  of  service  only  in 
impaction  of  feces  or  gall-stones  and  for  the  temporary  relief 
of  distressing  symptoms.  If  the  fecal  impaction  exists  in  the 
colon,  it  may  be  softened  by  introducing  a  steady  stream  of 
warm  water  to  which  bicarbonate  of  soda,  salt  and  glycerine 
has  been  added  in  the  proportion  of  an  ounce  of  each  to  the 
quart.  The  syringe  should  not  be  held  high  but  the  flow  should 
be  steadily  maintained.  The  first  part  of  feces  passing  away 
immediately  after  the  enema  are  but  the  contents  of  the 
rectum  and  not  the  impacted  mass.  It  is  sometimes  possible 
to  reach  the  impaction  with  a  rectal  scoop  but  unless  the  whole 
mass  can  be  scooped  away  the  enema  should  be  repeated  until 
softening  of  the  impacted  feces  has  been  accomplished.  Massage 
is  dangerous  as  injury  to  the  intestinal  wall  can  be  easily 
produced  by  rough  handling.  An  enema  will  not  go  beyond 
the  colon  and  impaction  beyond  that  must  be  reached  by  in- 
ternal medication.  The  fecal  mass  above  the  ileocecal  valve  be- 
ing fluid,  impaction  beyond  that  must  consist  of  gall-stones  or  a 
foreign  body.  The  following  mixture  has  served  well  in  such 
cases.  Croton  oil,  i  minim,  castor  oil  1/2  ounce  and  olive 
oil  31/2  ounces,  taken  in  one  dose  to  be  repeated  in  four  hours  if 
necessary.  A  minim  of  oil  of  peppermint  and  half  a  grain  of 
saccharin  will  disguise  the  smell  and  taste.  If  there  is  a  rapid 
intestinal  paresis,  eserine  in  1/50-grain  doses  may  be  used 
hypodermically  and  repeated  in  three  hours.  Slow  paresis 
must  be  overcome  by  the  internal  administration  of  persistaltic 
stimulants. 


INTESTINAL  OCCLUSION  325 

In  those  cases  in  which  there  is  a  permanent  or  slowly- 
advancing  partial  occlusion,  the  most  important  measure  is 
the  regulation  of  the  diet.  The  food  should  be  easily  digestible 
and  leave  little  waste.  Food  containing  much  cellulose,  seeds, 
rind,  nuts  and  all  other  substances  that  cannot  be  completely 
converted  must  be  avoided.  If  there  has  been  a  persistent 
constipation  for  several  days,  the  predigested  or  readily  con- 
verted foods  should  be  used,  but  those  containing  a  large  per- 
centage of  alcohol  must  not  be  taken.  Malted  milk  is  perhaps 
the  best  for  prolonged  use,  but  if  a  change  is  desired  any  of 
dry  and  non-alcoholic  liquid  foods  can  be  used.  If  a  cathartic 
is  required  castor  oil  will  act  best.  When  complete  occlusion 
occurs  surgical  intervention  is  necessary. 

Intestinal  Occlusion 

Etiology. — Any  cause  that  can  produce  partial  intestinal 
obstruction  may  also  produce  complete  occlusion,  and  many 
cases  of  partial  obstruction  proceed  to  complete  occlusion. 
The  most  frequent  causes  of  intestinal  occlusion  in  the  aged  are 
cancerous  growths  and  hernia.  Volvulus  and  kinks  are  also 
frequent  primary  causes.  Secondary  causes  are  paralysis  of 
the  bowel  associated  with  hemiplegia  or  paraplegia  or  following 
traumatism;  peritoneal  bands  following  peritonitis;  scar  tissue, 
completely  closing  the  gut;  occasionally  impaction,  rarely  intus- 
susception. 

Symptoms. — The  symptoms  of  intestinal  occlusion  come  on 
suddenly,  with  severe  abdominal  pain,  which  is  at  first  colicky, 
but  later  becomes  continuous.  There  is  generally  a  history  of 
constipation  and  in  some  cases  the  history  will  show  a  progres- 
sive partial  obstruction  which  had  reached  the  stage  of  com- 
plete occlusion.  Shortly  after  the  pain  sets  in,  vomiting  begins 
without  nausea  or  straining.  At  first  the  contents  of  the 
stomach  are  ejected  and  afterwards  a  greenish  or  brownish  bile- 
stained  fluid.  If  the  occlusion  occurs  in  the  duodenum  the 
ejected  matter  continues  to  be  bile-stained  but  is  not  feculent. 
The  fecal  odor  becomes  more  marked  the  farther  along  the 
gut  the  obstruction  occurs.  Tympanites  begins  about  the 
second  day  and  becomes  extreme  and  feculent  vomiting  sets 
in  about  the  third  day.     Collapse  may  occur  as   soon  as  the 


326  PATHOLOGICAL   OLD    AGE 

initial  pain  is  felt.  Usually,  however,  there  is  rapidly  deepen- 
ing mental  and  physical  depression,  while  collapse  sets  in  only 
after  the  stercoraceous  vomitus  appears. 

In  some  cases,  after  the  initial  pain  is  felt,  there  is  a  watery 
diarrhea  lasting  a  few  hours  then  complete  constipation.  Tenes- 
mus is  severe  if  the  occlusion  is  in  the  large  intestines  and  re- 
peated efforts  at  stool  may  being  forth  a  little  blood-stained 
mucus.  The  urine  is  either  suppressed  or  it  is  scanty  and  con- 
tains indican  and  phenol.  The  mind  is  clear  but  there  is  an 
intense  depression  associated  with  the  fear  of  dying.  The 
Facies  Hippocrates  may  appear  within  a  few  hours  after  the 
occlusion  has  occurred.  A  tumor  can  sometimes  be  felt  at  the 
site  of  the  occlusion,  while  above  that  point  the  intestine  bulges 
out  so  that  it  can  be  seen  and  felt. 

A  cancerous  growth  is  usually  recognized  long  before  it  has 
produced  complete  occlusion  of  the  gut.  It  is  generally 
located  in  the  colon  or  rectum;  but  occasionally  a  cancer  of  the 
mesentery  will  produce  intestinal  occlusion.  Hernia  may  be 
either  intraabdominal,  or  extraabdominal,  umbilical,  inguinal 
or  femoral.  It  is  impossible  to  diagnose  an  intraabdominal 
hernia  except  by  exclusion.  There  is  usually  a  history  of  trau- 
matism or  peritonitis.  The  obstruction  is  generally  in  the 
small  intestine,  there  is  early  fecal  vomiting,  no  tenesmus, 
little  or  no  meteorism  and  collapse  occurs  early.  The  extra- 
abdominal  hernias  are  readily  diagnosed  and  when  strangu- 
lated they  give  the  ordinary  symptoms  described.  Volvulus 
may  sometimes  be  recognized  as  a  painful  mass  in  the  left  iliac 
fossa,  with  intense  remissive  pain  and  marked  early  tympanites. 
It  is  comparatively  rare.  Kinks  usually  produce  chronic  intes- 
tinal stasis  but  may  sometimes  completely  close  the  lumen  of 
the  gut  and  produce  the  symptoms  of  occlusion.  There  will, 
however,  be  a  history  of  chronic  constipation  with  autointoxica- 
tion lasting  for  many  months.  Any  part  of  the  intestine  may 
be  bound  down  and  kinked,  and  a  variety  of  symptoms  refer- 
able to  the  intestinal  tract  are  thus  produced.  Intestinal 
paresis  is  readily  diagnosed  by  the  associated  paralysis.  Cica- 
tricial stricture  gives  a  history  of  duodenal,  syphilitic,  typhoid, 
or  tubercular  ulcer.  The  diagnosis  of  intestinal  occlusion  is 
simple  after  feculent  vomiting  has  set  in.  Before  this,  the 
pain  and  abdominal  distention  may  be  mistaken  for  appen- 


Extensive  protruding  internal  hemorrhoids.     (From  Gant's  "Constipation.") 


HEMORRHOIDS  2>27 

dicitis  or  peritonitis,  but  these  diseases  are  accompanied  by 
fever  and  chills.  Hepatic  colic  with  constipation  may  simulate 
occlusion.  The  remission  of  pain,  the  jaundice,  light-colored 
stools,  location  of  colic,  and  the  history,  will  distinguish  the  two. 
Treatment. — The  treatment  is  purely  surgical  and  should  be 
undertaken  as  soon  as  the  diagnosis  of  intestinal  occlusion  is  es- 
tablished. Morphine  and  atropia  may  be  given  in  the  interim 
to  relieve  pain,  and  gastric  irritation  may  be  allayed  by  lavage, 
but  nothing  will  relieve  the  obstruction  except  an  operation. 
After  collapse  has  occurred  the  case  is  hopeless. 

HEMORRHOIDS 
Hemorrhoidal  Varix 

Etiology. — Hemorrhoids  occur  frequently  in  persons  past 
maturity  owing  to  the  greater  tendency  to  venous  stasis  and 
the  weakening  of  the  venous  walls,  which  permit  their  dilata- 
tion. They  are  mostly  internal  piles  which  protrude  through 
the  relaxed  sphincter  and  in  most  cases  are  due  to  pressure 
upon  the  hemorrhoidal  veins  by  feces  that  are  retained  in  the 
rectum.  The  underlying  cause  is  that  of  rectal  constipation. 
Stricture,  and  tumors  of  the  rectum  or  of  adjacent  organs, 
which  press  upon  the  hemorrhoidal  veins,  may  also  cause  hemor- 
rhoidal varix. 

Symptoms. — External  piles  are  seldom  sufficiently  distres- 
sing to  require  medical  attention.  They  appear  as  tumors, 
ranging  in  size  from  a  pea  to  a  marble,  situated  outside  of  the 
anal  sphincter.  When  inflamed  or  eroded  by  the  friction  of 
the  feces,  or  by  scratching  where  there  is  an  accompanying 
pruritus,  the  surface  is  reddened  or  ulcerated,  and  painful.  In 
rare  instances  there  will  be  a  hemorrhage;  more  often  there  is 
pruritus  and  eczema  around  the  tumor,  and  the  skin  becomes 
strongly  pigmented  and  infiltrated.  Internal  piles  in  the  aged 
generally  protrude  from  the  anus  after  defecation  and  some- 
times they  remain  permanently  outside  where  the  sphincter  is 
lax.  If  returned  within  the  rectum  a  slight  strain  will  force 
them  out  again.  They  are  readily  recognized  by  their  bluish 
appearance,  doughy  feel  and  motility  under  the  mucous  mem- 
brane   which    covers    them.     They    are    frequently    inflamed, 


328  PATHOLOGICAL    OLD    AGE 

excoriated  or  ulcerated  from  the  irritation  of  the  feces,  and 
when  in  this  condition  they  are  painful  and  bleed  readily. 
There  is  often  an  itching  eczematous  area  around  them,  the 
skin  becomes  anesthetic,  infiltrated  and  pigmented  and  may 
become  ulcerated.  If  the  sphincter  ani  has  retained  its  tonicity 
an  internal  hemorrhoid  which  had  been  forced  out  may  become 
strangulated,  the  enclosed  blood  stagnates  and  coagulates 
there  and  the  tumor  will  be  converted  into  a  cystic  mass,  or 
may  become  gangrenous.  Defecation  may  cause  an  inflamma- 
tion about  the  base  of  the  pile,  and  this  periphlebitis,  extending 
to  the  interior,  produces  a  phlebitis.  A  proctitis,  periproctitis, 
rectal  abscess,  anal  fissures  and  fistulas  are  occasional  complica- 
tions. The  pain  is  usually  not  severe  unless  inflammation, 
erosion  or  ulceration  occurs.  When  hemorrhage  occurs  it  almost 
always  accompanies  defecation.  In  these  cases  there  is  generally 
a  voluntary  constipation,  the  patient  fearing  that  defecation 
will  produce  pain  or  force  out  the  pile.  There  may  be  tenesmus 
caused  by  irritation  of  the  rectal  wall,  and  there  is  sometimes  a 
vesical  irritation.  In  rare  cases  the  pile  is  situated  in  the  upper 
part  of  the  rectum  and  is  there  more  liable  to  become  inflamed 
and  to  bleed.  The  cause  or  source  of  the  hemorrhage  may  be 
a  puzzle  until  an  examination  with  the  finger  or  proctoscope  is 
made.  It  is  hardly  possible  to  mistake  hemorrhoids  for  any 
other  condition.  Rectal  and  anal  ulcers  may  bleed  but  do  not 
present  tumors.  A  carcinoma  of  the  rectum  is  painful  and 
rapid  in  its  course;  a  polypoid  bleeding  growth  does  not  have 
the  color  or  consistency  of  the  pile  and  breaks  down  upon 
slight  friction. 

Treatment. — Hemorrhoids  in  the  aged  are  usually  less  dis- 
tressing than  in  earlier  life  and  may  exist  for  years  before  a 
local  pruritus,  eczema  or  inflammation  attracts  the  patient's 
attention  to  them.  As  soon  as  piles  cause  distress  the  annoying 
symptoms  should  be  treated.  For  the  pruritus  we  can  follow 
the  treatment  suggested  in  the  chapter  on  Senile  pruritus  and 
the  eczema  is  to  be  treated  as  recommended  in  the  chapter  on 
this  disease.  Where  there  is  an  erosion  or  ulceration  upon,  or 
in  the  vicinity  of  a  hemorrhoid,  the  surface  should  be  covered 
with  equal  parts  of  subnitrate  of  bismuth  and  aristol  over  which 
a  thick  layer  of  unguentum  petrolatum  is  to  be  applied  in  order 
to  protect  the  lesion  from  the  irritation  produced  by  the  fecal 


BILIARY  OBSTRUCTION  329 

discharges.  If  there  is  much  pain  in  the  pile  a  2  per  cent,  co- 
caine ointment,  using  a  lanoline  base,  should  be  used.  This 
will  generally  give  immediate  relief,  but  if  after  two  or  three 
applications,  the  relief  is  not  permanent  the  extract  of  bella- 
donna should  be  substituted  for  the  cocaine.  Inflammation 
is  best  treated  by  applications  of  ice  water  (not  ice),  and,  if 
there  is  hemorrhage,  adrenalin  in  1/10-per  cent,  solution  will 
check  it.  Astringents  will  also  check  hemorrhage  but  they  may 
produce  a  contraction  of  the  anal  sphincter  and  constrict  the 
pile  or,  contracting  the  rectal  wall,  cause  constipation.  If 
operative  procedure  becomes  necessary  the  choice  of  operation 
must  be  left  to  the  surgeon. 

BILIARY  OBSTRUCTION 

Etiology. — Partial  biliary  obstruction  occurs  generally  from 
impaction  of  gall-stones  or  inspissated  bile  in  some  part  of  the 
duct.  Other  causes  of  biliary  obstruction  are  impaction  by 
concretions  or  parasites,  inflammation  of  the  duct  or  of  the 
duodenum  about  the  mouth  of  the  common  duct,  contraction 
following  angiocholitis,  growths  in  the  ducts,  or  pressure  upon 
the  duct  by  a  growth  in  neighboring  tissues;  aneurysm,  fecal 
impaction  or  bands  of  adhesions.  It  is  often  impossible  to 
determine  the  cause  of  the  obstruction,  but  other  causes  than 
impaction  by  gall-stones  or  inspissated  bile  are  rare.  An 
angiocholitis  may  occur  as  an  extension  of  an  inflammation  of 
the  duodenum,  or  may  be  due  to  irritation  following  the  passage 
of  a  gall-stone.  In  most  cases  it  is  caused  by  the  invasion  of 
microorganisms,  the  colon  bacilli,  streptococci  and  staphy- 
lococci being  generally  found  in  the  bile  passages  and  in  the 
bile  of  patients.  In  angiocholitis  the  mucous  membrane  is 
thickened  and  covered  with  thick  tenaceous  mucus,  and  if  due 
to  infection  the  secretion  is  mucopurulent.  The  swelling  of 
the  membrane  usually  produces  a  partial  occlusion,  but  it  may 
entirely  obliterate  the  lumen  of  the  duct. 

There  is  no  direct  method  of  diagnosing  angiocholitis  nor 
can  a  presumptive  diagnosis  be  made  before  jaundice  appears. 
If  symptoms  of  gastroenteritis  precede  the  jaundice,  there  has 
probably  been  an  extension  of  the  inflammation  into  the  duct. 
In  this  case  there  is  a  slowly  increasing  jaundice.     Gradually 


330  PATHOLOGICAL    OLD    AGE 

all  the  symptoms  improve  and  the  jaundice  will  dissappear  at 
the  same  time.  If  there  is  fever,  and  later,  a  hepatitis  with 
swelling  and  pain  on  pressure,  the  angiocholitis  is  due  to  infec- 
tion. The  symptoms  are  those  of  acute  septic  infection  asso- 
ciated with  jaundice  and  clay-colored  stools. 

Contraction  of  the  duct  may  produce  the  symptoms  of  bili- 
ary obstruction.  The  diagnosis  rests  upon  the  history  of  a  pre- 
ceding angiocholitis,  the  former  giving  no  pathognomonic 
symptoms. 

Growths  cannot  be  positively  diagnosed  unless  they  can 
be  felt.  Cancer  gives  the  distinctive  symptoms  of  such  neo- 
plasms, pain,  and  tenderness,  the  presence  of  a  growth,  rapid 
emaciation,  progressive  weakness,  cachexia,  and  the  involve- 
ment of  neighboring  tissues  and  lymph  glands.  Aneurysm  of 
the  aorta,  hepatic  or  mesenteric  arteries  usually  give  distinctive 
symptoms.  These  conditions  are,  however,  very  rare  in  the 
aged  and  still  rarer  is  occlusion  produced  by  fibrous  bands  of 
adhesion  resulting  from  peritonitis.  They  produce  complete 
and  rapid  occlusion  with  profound  systemic  disturbance  for 
the  relief  of  which  surgical  interference  is  generally  necessary. 
Fecal  impaction  is  rarely  massive  enough  to  occlude  the  gall- 
ducts,  and  when  it  does  occur  it  is  usually  relieved  in  a  few 
days.  Obstruction  due  to  gall-stones  or  concretions  is  usually 
accompanied  by  the  symptoms  of  gall-stones.  These  are  par- 
oxysmal pain  and  cramps  with  jaundice  and  intestinal  distur- 
bance due  to  deficiency  of  bile.  In  some  cases  it  may  be  neces- 
sary to  make  the  diagnosis  by  exclusion. 

Symptoms.— The  symptoms  of  biliary  obstruction  depend 
in  part  upon  the  location,  and  in  part  upon  the  degree  of  occlu- 
sion. The  most  prominent  symptoms  are  jaundice  and  clay- 
colored  stools,  but  if  the  cystic  duct  is  occluded,  both  may  be 
absent.  The  obstruction  may  be  in  the  hepatic,  cystic  or 
common  duct.  If  in  the  hepatic  duct  we  must  exclude  gall- 
stones. If  in  the  cystic  duct  the  bile  may  flow  from  the  liver 
through  the  hepatic  and  common  ducts  to  the  duodenum, 
thereby  preventing  retention  of  bile  with  the  consequent  jaun- 
dice and  clay-colored  stools.  In  such  case  the  gall-bladder  is 
unable  to  discharge  its  contents  and  these  may  cause  inflam- 
mation or  dilatation,  or  else  calcareous  or  atrophic  degeneration. 
Dilatation   is  rare  in  the  aged  as  there  is  generally  atrophy 


BILIARY  OBSTRUCTION  33 1 

of  the  mucous  membrane  and  of  the  glands.  If  the  glands 
are  still  active,  the  gall-bladder  may  become  distended  with 
mucus  and  bile,  and  where  the  abdominal  walls  are  thin,  the 
viscus  can  be  felt  as  a  pouch  below  and  to  the  right  of  the 
sternum.  Inflammation  occurs  occasionally,  and  almost  always 
as  a  result  of  infection.  A  simple  catarrhal  cholecystitis  may 
occur  through  extension  of  an  angiocholitis,  or  from  an  irrita- 
tion produced  by  the  gall-stones  contained  in  the  gall-bladder, 
especially  may  this  happen  after  rough  manipulation  of  the 
distended  organ.  The  only  symptom  pointing  to  catarrhal 
cholecystitis  is  pain  and  tenderness  over  the  region  of  the 
gall-bladder.  In  infectious  cholecystitis  there  are,  in  addition, 
the  constitutional  symptoms  of  septic  infection,  chills,  fever, 
nausea,  vomiting,  distention  of  the  abdomen,  etc.  In  these 
cases  surgical  measures  are  required  to  determine  the  exact 
condition  and  to  relieve  the  distended  organ.  In  most  cases 
of  obstruction  of  the  cystic  duct,  the  gall-bladder  undergoes 
calcareous  and  atrophic  degeneration,  the  contained  gall-stones 
becoming  encapsulated.  If  the  hepatic  duct  is  obstructed, 
jaundice  and  light-colored  stools  appear  and  the  liver  becomes 
congested  but  the  gall-bladder  is  not  affected.  If  the  obstruc- 
tion is  in  the  common  duct,  however,  the  gall-bladder  becomes 
distended  with  bile  that  had  been  dammed  back  from  the 
point  of  obstruction.  Clay-colored  or  light-colored  stools  con- 
taining undigested  fat  indicate  a  diminution  in  the  bile  supply 
to  the  intestines.  If  this  occurs  without  jaundice  the  fault 
lies  in  the  liver,  which  is  not  elaborating  sufficient  bile,  while 
a  fairly  dark  stool  with  jaundice  points  to  obstruction  of 
some  of  the  bile  ducts  in  the  liver.  The  stools  in  biliary  ob- 
struction are  pasty  and  foul  smelling.  Sometimes  there  is 
constipation  then  again  diarrhea  as  soon  as  intestinal  decom- 
position causes  irritation  of  the  bowel. 

The  most  important  symptom  of  biliary  obstruction  is 
jaundice.  The  toxemic  jaundice  is  readily  differentiated  by 
the  presence  of  an  acute  infection,  or  of  arsenic  or  phosphorus 
poisoning,  in  these  cases  the  jaundice  is  not  severe,  the  stools 
are  bile-stained  and  the  accompanying  symptoms  of  obstruc- 
tive jaundice,  pruritus,  sweating  and  bradycardia  are  not 
marked.     Indeed,  they  may  be  absent. 

The  jaundice  due  to  obstruction  of  some  of  the  bile  ducts 


332  PATHOLOGICAL   OLD   AGE 

in  the  liver  may  be  mistaken  for  the  jaundice  of  an  infec- 
tious disease,  as  the  stools  are  bile-stained  and  all  the  other 
symptoms  are  mild,  but  there  are  no  symptoms  of  the  infectious 
disease  and  bile  pigment  can  be  found  in  the  urine.  Jaundice 
may  occur  in  chronic  hepatitis,  cirrhosis,  cancer  and  other 
pathological  states  of  the  liver,  but  it  is  a  late  symptom  of 
these  diseases. 

Treatment. — The  treatment  of  biliary  obstruction  depends 
upon  the  cause.  The  treatment  for  cholelithiasis  is  given  else- 
where. In  catarrhal  angiocholitis  the  alkaline  mineral  waters 
should  be  used,  and  sodium  salicylate  may  be  given  in  5 -grain 
doses  combined  with  1  dram  of  sodium  phosphate  every  four 
hours.  In  all  cases,  whatever  the  cause  may  be,  sodium  choleate 
should  be  given  in  3 -grain  doses  after  each  meal.  Potassium 
bicarbonate  will  increase  the  fluidity  of  the  bile.  Calomel  in 
1/10-grain  doses  every  two  hours  will  increase  the  activity  of 
the  liver,  but  in  most  cases  the  fault  does  not  lie  in  this  organ, 
therefore,  hepatic  stimulants  are  contraindicated.  The  attend- 
ing symptoms,  especially  the  often  distressing  pruritus,  can  be 
temporarily  relieved  by  washing  the  body  with  a  i-per  cent, 
solution  of  cocaine.  In  some  cases  a  2 -per  cent,  solution  of 
carbolic  acid  in  oil  will  help,  in  others  hot  water  or  cold  water 
will  relieve  the  itching. 

CHRONIC  INTERSTITIAL  NEPHRITIS 

Chronic  interstitial  nephritis  is  the  most  frequent  of  the  renal 
affections  found  in  the  aged.  It  is,  however,  not  as  frequent  as 
the  reports  of  pathologists  would  indicate,  for  pathologists 
still  call  the  normal  senile  contracted  kidney  interstitial  nephri- 
tis, and  physicians  still  diagnose  every  persistent  albuminuria 
as  Bright 's  disease,  especially  if  there  are  concomitant  nervous 
symptoms.  Walsh  has  pointed  out  that  there  is  a  physiological 
increase  of  connective-tissue  growth  between  the  apices  of  the 
pyramids  going  on  from  birth  throughout  life.  This  hyper- 
plasia is  most  marked  in  old  age  when  arteriosclerotic  nutri- 
tional changes  cause  atrophy  of  other  renal  tissue.  Faulty  no- 
menclature is  partly  responsible  for  the  confusion  in  diagnosis, 
since  several  distinct  conditions  are  included  under  this  term 
while  the  same  condition  has  received  several  names.     Chronic 


Kidney  Showing  Advanced  Chronic  Interstitial 
Nephritis.  (Natural  size.)  A.  Ureter.  B.  Small 
cyst  just  under  capsule.  The  irregularly  lobulated, 
coarsely  and  finely  granular  surface  is  well  shown. 
(From  Coplin's  "Manual  of  Pathology.") 


■;        .,      -     ;        -        -■■>-- 


■'"•"■'■-■•.:: 


"    -    -"  •  : 


c 
Kidne)7,  chronic  interstitial  nephritis.     (From  Coplin's  ''Manual  of  Pathology.") 


CHRONIC  INTERSTITIAL  NEPHRITIS  333 

interstitial  nephritis,  renal  cirrhosis,  sclerosis  of  the  kidney, 
granular  kidney,  gouty  kidney,  contracted  kidney,  atrophic 
kidney,  are  all  names  used  for  this  disease,  while  the  same  term 
is  also  applied  to  (i)  a  secondary  condition  following  parenchy- 
matous nephritis  called  also  small  white  kidney,  (2)  to  a  primary 
pathological  degenerative  process,  and  (3)  to  the  normal  senile 
degeneration,  generally  due  to  renal  arteriosclerosis.  The  last 
of  these  is  the  normal  senile  contracted  kidney,  the  ' '  rein  senile ' ' 
of  the  French.  The  term  chronic  interstitial  nephritis  is  here 
applied  to  signify  a  primary  pathological  degeneration,  or  per- 
version of  the  normal  degeneration  and  not  to  the  secondary 
involvement  of  interstitial  tissue  following  parenchymatous 
nephritis. 

Etiology. — The  usual  cause  of  chronic  interstitial  nephritis 
in  the  aged  is  excessive  work  imposed  upon  the  physiological 
contracted  kidney.  The  senile  kidney  cannot  eliminate  waste 
material  as  rapidly  nor  as  actively  as  before  and  it  is  forced  to 
increased  activity  whenever  such  material  is  produced  in  excess 
— as  in  excessive  ingestion  of  food,  especially  of  meat — or  when- 
ever waste  is  retained  in  excess,  as  in  constipation,  and  when 
abnormal  material  must  be  eliminated  such  as  lead,  iodine, 
mercury,  or  the  products  of  imperfect  metabolism,  etc.  Any 
cause  responsible  for  an  increase  in  any  of  the  normal  con- 
stituents, or  for  the  production  of  abnormal  ingredients  in  the 
urine,  is  also  the  cause  of  excessive  activity  or  irritation  of  the 
kidney  and  consequent  degeneration.  We,  therefore,  find  it 
after  prolonged  physical  or  mental  labors,  indiscretions  in  food 
or  drink,  in  gout,  chronic  rheumatism,  diabetes  and  other  con- 
ditions due  to  impaired  or  perverted  metabolism.  The  toxins 
of  infectious  diseases  cause  a  parenchymatous,  rarely  an  inter- 
stitial degeneration  although  the  latter  may  follow  as  a  second- 
ary affection  through  extension  of  the  degeneration. 

Pathology. — The  kidney  of  interstitial  nephritis  resembles 
the  normal  contracted  kidney  in  being  small,  rough,  dense, 
dark  red  in  color,  granular  and  having  a  closely  adherent  cap- 
sule. There  is  an  atrophy  of  the  cortex,  while  the  region  of  the 
pyramids  exhibits  a  hyperplasia  of  connective  tissue.  The 
difference  between  the  normal  senile  kidney  and  the  kidney  of 
interstitial  nephritis  is  readily  seen  under  the  microscope.  In 
the  latter  condition  there  are  found  hyaline  and  fatty  degenera- 


334 


PATHOLOGICAL    OLD    AGE 


tion  and  cloudy  swelling  of  the  tufts,  capillary  vessels,  and 
between  the  loops,  the  tubules  are  filled  with  casts  and  granular 
matter  and  some  of  the  smaller  vessels  and  glomeruli  are  de- 
stroyed. These  degenerative  changes  are  not  found  in  the 
normal  senile  contracted  kidney. 

Symptoms. — It  is  impossible  to  distinguish  between  the 
early  symptoms  of  chronic  interstitial  nephritis  and  the  normal 
senile  kidney.  A  more  or  less  persistent  trace  of  albumin  is 
present  in  both  and  the  early  nervous  and  visceral  symptoms 
may  be  due  to  the  senile  degeneration  of  the  organs.  The 
diagnosis  must  be  made  by  carefully  examining  the  urine.  In 
nephritis  the  quantity  is  increased  and  the  specific  gravity  is 
lower  than  normal.  We  must  remember  that  the  normal 
output  in  the  aged  is  from  iooo  to  1200  c.c.  in  the  male  and 
from  900  to  1000  c.c.  in  the  female  and  what  would  be  normal 
in  maturity  is  a  polyuria  in  old  age.  The  specific  gravity  in 
interstitial  nephritis  is  sometimes  as  low  as  1.01  or  even  less. 
The  finding  of  a  single  hyaline,  fatty  or  granular  cast  determines 
the  diagnosis  and  this  will  be  confirmed  by  other  symptoms. 
The  patient  must  get  up  at  night  to  empty  the  bladder.  The 
aged  usually  get  up  once  or  twice  a  night  for  this  purpose  if 
they  have  a  dilatation  of  the  bladder  but  if  one  gets  up  several 
times  at  night  it  points  to  nephritis.  Cardiac  hypertrophy 
and  high  blood  pressure  are  constant  attendants.  A  per- 
sistent high  blood  pressure  without  arteriosclerosis  is  almost 
pathognomonic  of  this  disease.  Edema  of  the  ankles  may 
occur  but  this  is  rarely  extensive  until  the  heart  is  seriously 
involved.  In  many  cases  there  are  intermittent  severe  head- 
aches, sometimes  hemicrania,  often  insomnia  and  restlessness- 
Dyspnea  and  asthmatic  attacks  may  occur.  Later  gastric  symp- 
toms, anorexia,  indigestion  and  irregular  bowel  action  are 
noticed.  The  skin  becomes  dry  and  there  may  be  pruritus  or 
eczema.  Nervous  symptoms  appear  later,  such  as  tinnitus, 
disorders  of  sight,  muscle  twitching,  cramps,  etc.  Diffuse 
retinitis  and  retinal  hemorrhages,  which  occur  frequently  in 
younger  individuals,  are  infrequent  in  the  aged.  The  uremic 
convulsions  which  generally  appear  toward  the  termination  of 
this  disease  in  earlier  life  occur  rarely  in  the  old,  the  patient 
usually  succumbing  to  an  intercurrent  disease,  such  as  pneu- 
monia, pulmonary  edema  or  heart  disease. 


CHRONIC  INTERSTITIAL  NEPHRITIS  335 

Diagnosis. — It  is  important  to  differentiate  between  the 
senile  contracted  kidney  and  the  kidney  of  chronic  interstitial 
nephritis.  In  the  normal  senile  kidney  the  amount  of  urine  is 
diminished,  the  specific  gravity  is  but  slightly  if  at  all  lowered, 
the  urates  are  but  slightly  decreased  and  there  are  no  casts. 
If  there  are  cardiac,  nervous  or  other  symptoms,  each  symp- 
tom must  be  traced  to  its  source  and  cause.  If  there  is  frequent 
urination  at  night  we  must  look  for  a  dilated  bladder  and  en- 
larged prostate.  High  blood  pressure  may  be  due  to  arterio- 
sclerosis. The  headache,  gastric  disorders,  and  nervous  symp- 
toms must  be  considered  one  by  one  and  their  cause  determined. 

The  gouty  kidney,  which  gives  symptoms  of  interstitial 
nephritis,  can  be  diagnosed  by  other  symptoms  of  gout.  The 
secondary  contracted  kidney  or  small  white  kidney  follows 
chronic  parenchymatous  nephritis  which  gives  pronounced 
symptoms.  It  must  be  remembered  that  in  all  cases  of  neph- 
ritis the  diagnosis  depends  primarily  upon  the  urinary  analysis, 
other  symptoms  being  merely  corroborative.  If  after  repeated 
examination  no  casts  appear  at  any  time  we  can  exclude  neph- 
ritis. The  primary  interstitial  nephritis  has  few  casts,  these  are 
chiefly  hyaline,  and  has  but  a  scanty  sediment.  Other  forms 
of  nephritis  have  numerous  casts  and  an  abundant  sediment. 
In  both  the  primary  and  secondary  interstitial  nephritis  the 
quantity  of  urine  is  increased  but  the  specific  gravity  of  the 
latter  is  but  slightly  reduced,  while  in  the  former  it  is  very  low. 
The  presence  of  albumin  does  not  necessarily  imply  nephritis, 
nor  does  its  absence  exclude  this  disease.  It  is  always  present 
in  abundance  in  the  parenchymatous  form  and  it  is  present  in 
small  quantities  in  the  secondary  interstitial  form.  It  may, 
however,  be  absent  for  some  time  in  the  primary  form  while  a 
trace  may  persist  in  the  normal  senile  kidney. 

Treatment. — Degenerated  tissue  cannot  be  restored.  The 
most  we  can  hope  to  do  is  to  avoid  everything  that  causes 
or  hastens  the  degeneration  and  to  relieve  symptoms  or  sec- 
ondary conditions  by  drug  medications.  Where  the  causative 
condition  is  controllable  we  can  sometimes  expect  an  improve- 
ment in  the  condition  of  the  kidneys,  as  may  be  seen  in  the 
gouty  kidney  under  the  treatment  for  gout.  The  general  treat- 
ment of  the  senile  kidney  is  hygienic  and  dietetic.  The 
dietetic  regulation  is  the  most  important  and  often  the  most 


336  PATHOLOGICAL   OLD    AGE 

difficult  factor  in  the  treatment  of  senile  cases.  The  patient 
should  have  a  varied  diet  including  all  the  food  elements  re- 
quired for  nutrition  and  in  sufficient  quantity  to  maintain 
normal  weight.  From  this  diet  he  must  exclude  as  far  as 
possible  those  substances  that  give  the  kidney  excessive  work, 
and  those  that  would  cause  indigestion  or  constipation.  The 
most  important  substances  to  be  excluded  or  diminished  in 
quantity  are  proteids,  salt,  alcohol  and  an  excessive  amount  of 
fluid.  Meat  should  be  taken  sparingly  and  omitted  for  several 
days  at  a  time.  The  least  harmful  are  the  light  meats,  chicken, 
game  and  bacon.  Broths  are  as  injurious  as  meats.  Vegetables 
except  legumes,  cereals  and  other  farinaceous  foods,  fruits, 
fish  and  shell  fish  are  admissible.  Coffee  and  tea  should  be 
used  sparingly  but  milk  and  buttermilk  may  be  taken  freely. 
The  amount  of  salt  should  be  diminished  but  a  salt-free  diet  is 
inadvisable  unless  there  is  edema,  an  infrequent  contingency 
in  the  aged.  Alcohol  should  be  forbidden  unless  the  patient 
is  accustomed  to  it,  when  the  quantity  should  be  gradually 
reduced.  Alkaline  mineral  waters  free  from  sodium  chloride, 
preferably  the  natural  lithia  waters,  are  serviceable  to  prevent 
the  formation  of  fibrinous  plugs  in  the  tubules.  The  hygienic 
regulations  are  a  strict  enforcement  of  the  ordinary  rules  of 
health  as  applied  to  the  invalid.  Mental  and  physical  fatigue 
should  be  avoided.  Strong  emotions  and  prolonged  worry 
are  detrimental,  while  mild  pleasurable  mental  and  physical 
stimuli  are  beneficial.  Moderate  exercise,  stopping  short  of 
fatigue,  should  be  taken,  and  warm  baths  are  beneficial. 

Drug  medication  is  indicated  as  soon  as  distressing  symp- 
toms arise  or  whenever  there  is  danger  of  grave  complications, 
or  for  the  treatment  of  the  latter.  For  anorexia  the  simple 
bitters  or  orexin  can  be  used.  The  bowels  must  be  kept  open 
and  for  this  purpose  aloin  combined  with  the  bile  salts  is  in- 
dicated. The  bile  salts  aid  in  preventing  intestinal  decomposi- 
tion. Iron  is  frequently  recommended  in  this  disease,  but  in 
the  aged  where  there  is  high  arterial  tension  it  is  contraindicated. 
When  the  blood  pressure  is  very  high  and  there  is  danger  of 
cerebral  anemia  or  venous  stasis  the  nitrites  must  be  employed, 
using  preferably,  the  i-per  cent,  spirit  of  glonoin  in  1 -minim 
doses  every  three  hours  until  the  face  becomes  flushed  and  re- 
mains flushed  for  a  few  minutes.    It  should  then  be  discontinued. 


RENAL  CALCULUS  337 

Diuretics  are  rarely  indicated  unless  the  degeneration  involves 
the  parenchyma  and  the  amount  of  urine  is  markedly  dimin- 
ished. This,  however,  rarely  happens.  When  diuretics  be- 
come necessary,  renal  irritants,  including  the  essential  oils  and 
oleoresins,  should  be  avoided.  In  such  case  the  sodium  or 
potassium  nitrate  should  be  employed.  In  senile  cases  we  must 
bear  in  mind  not  only  the  condition  of  the  kidneys  but  the 
condition  of  the  whole  degenerate  organism. 

UROLITHIASIS 

Renal  and  vesical  calculi  are  frequent,  the  vesical  calculus 
almost  invariably  originating  as  a  renal  concretion.  The  two 
forms  of  urolithiasis  will  be  described  separately. 

Renal  Calculus 

Renal  calculi  occur  frequently,  sometimes  without  giving 
any  symptoms  of  their  presence.  When  minutely  small  they 
pass  away  with  the  urine  unnoticed,  forming  an  insoluble  sedi- 
ment ;  when  larger  they  produce  a  local  irritation  in  the  ureters, 
bladder  and  urethra  and  pass  away  as  gravel,  or  coarser  sedi- 
ment. Still  larger  concretions  pass  through  the  ureters  with 
difficulty  and  produce  the  painful  symptom-complex  of  renal 
colic.  If  too  large  to  pass  through  the  ureter  the  renal  calculus 
becomes  impacted  or  imbedded  in  the  pelvis  of  the  kidney. 
The  concretion  generally  consists  of  uric  acid,  sometimes  of 
urates  or  phosphates,  occasionally  of  calcium  or  carbonate 
oxalate,  cystin,  xanthin,  fibrin,  etc.  The  experiments  of  Eb- 
stein  and  Nicolaier  have  shown  that  the  structure  of  the  renal 
calculus  is  an  albuminous  framework  filled  with  calcareous 
material,  deposited  either  in  concentric  layers,  scales  or  threads, 
or  else  as  irregular  crystals.  The  growth  of  the  calculus  keeps 
pace  with  the  growth  of  the  framework.  The  nucleus  of  the 
stone  may  be  a  microscopic  crystal,  pus,  blood,  pigment,  fat, 
fibrin,  cystin,  tube  cast  or  other  urinary  constituent,  microor- 
ganisms or  parasitic  ovum.  The  framework  is  derived  from  an 
inflammatory  process  in  the  kidney,  the  calcareous  material 
from  the  urine. 

Etiology. — Two  etiological  factors  are  necessary  for  the  pro- 
duction of  renal  calculi;  one  which  will  cause  the  production  of 


22 


338  PATHOLOGICAL   OLD   AGE 

the  framework,  the  other  which  will  cause  a  change  in  the 
character  of  the  urine.  Anything  which  will  produce  an  irrita- 
tion of  the  kidney  will  cause  a  mild  catarrhal  inflammation 
with  secretion  of  mucus  from  which  the  framework  material 
is  obtained.  A  highly  acid  urine  or  any  other  renal  irritant 
may  do  this.  The  most  frequent  change  in  the  character  of 
the  urine  is  an  excess  of  urea  or  uric  acid,  and  we  find,  conse- 
quently, that  uric  acid  calculi  occur  in  the  aged  more  frequently 
in  connection  with  gout.  Drinking  excessive  quantities  of 
earthy  mineral  waters  predisposes  to  phosphatic  calculi.  The 
derivation  of  the  ammonium-magnesium  phosphate  in  phos- 
phatic renal  calculi  is  not  clear,  as  the  ammonia  element  is  pro- 
duced in  the  decomposition  of  urine  and  such  decomposition 
in  the  kidneys  is  generally  due  to  bacterial  infection.  When 
this  occurs  pyelitis  usually  results,  yet  calculi  of  triple  phos- 
phates have  been  found  in  the  kidney  without  any  other  kidney 
involvement. 

Symptoms. — In  some  cases  there  are  no  symptoms  to  indi- 
cate the  presence  of  a  renal  calculus.  In  most  cases,  if  the 
calculus  remains  in  the  kidney,  there  is  a  dull  ache  in  the  lumbar 
region,  with  occasional  pains  shooting  downward  and  forward 
toward  the  bladder,  or  down  to  the  thighs.  The  pain  is  aggra- 
vated by  anything  that  would  disturb  the  position  of  the  stone, 
as  jolting,  horseback  riding,  jumping,  etc.  This  is  occasionally 
followed  by  hematuria  and  pyuria.  Septic  symptoms  may 
arise.  Small  calculi  generally  pass  from  the  kidney  to  the 
bladder,  producing  during  their  passage  through  the  ureter  the 
symptoms  of  renal  colic.  There  is  a  sudden  intense  pain  extend- 
ing from  the  kidney  to  the  testicles  or  labia,  especially  severe 
at  the  point  where  the  stone  is  momentarily  lodged  in  the  ureter. 
There  is  at  the  same  time  a  sharp  pain  at  the  end  of  the  penis, 
and  the  testicle  on  the  affected  side  is  retracted.  There  is 
also  a  constant  desire  to  urinate,  but  only  a  few  drops  are  passed 
at  a  time,  and  the  urine  is  then  generally  blood-stained.  The 
usual  concomitants  of  shock  are  present,  namely,  intense  pain, 
an  anxious,  pale,  pinched  countenance,  covered  with  cold  per- 
spiration, nausea  and  vomiting,  small  pulse,  slight  elevation  of 
temperature  and  collapse.  The  symptoms  abate  as  soon  as 
the  calculus  has  entered  the  bladder,  the  time  of  passage  vary- 
ing, generally  from  one  hour  to  a  day.     The  aching  pain  across 


Heberden's  nodes.     (Courtesy  of  S.  Epstein,  M.  D.,  New  York.) 


RENAL  CALCULUS  339 

the  back  may  continue  for  two  or  three  days,  but  is  gradually 
diminishing  in  severity.  Immediately  after  the  passage  of  the 
stone  into  the  bladder  there  is  a  copious  flow  of  urine  which  may 
contain  albumin,  casts  and  blood.  Occasionally  a  calculus 
becomes  impacted  in  some  part  of  the  ureter.  In  such  case  the 
colicky  pains  will  persist  for  days  with  a  gradually  diminishing 
intensity.  A  hydronephrosis  follows,  but  if  the  other  kidney 
is  healthy  this  will  give  no  symptoms  until  the  excessive  work 
imposed  upon  the  healthy  kidney  causes  its  degeneration. 
Pyonephrosis  and  pyelitis  may  follow  septic  infection. 

The  urine  is  acid  if  there  is  a  uric  acid  calculus  and  alkaline 
if  there  is  a  phosphatic  or  oxalic  concretion. 

Treatment. — A  stone  impacted  in  a  ureter  or  so  situated 
in  the  kidney  as  to  interfere  with  the  discharge  of  the  urine, 
thereby  producing  much  distress,  or  causing  inflammation, 
must  be  removed  by  surgical  means.  If  there  is  but  distress 
without  inflammation  and  no  interference  with  the  excretion  of 
urine,  medicinal  measures  may  first  be  tried.  The  best  drug 
for  dissolving  uric  acid  calculi  is  piperazine.  This  should 
be  given  with  alkaline  waters,  acetate  or  citrate  of  potash, 
citrate  of  lithia,  benzoate  of  soda  or  any  other  alkaline  salt 
which  will  render  the  urine  alkaline.  If  the  urine  is  alkaline, 
pointing  to  phosphatic  stone,  the  first  indication  is  to  render  it 
acid  by  benzoic,  boracic,  or  the  mineral  acids.  Theoretically 
this  should  dissolve  the  stones.  Prolonged  acid  medication  has 
been  followed  by  renal  colic.  It  would  appear  that  the  acid 
diminishes  the  size  of  the  calculus  and  enables  it  to  pass  through 
the  ureter. 

In  the  vast  majority  of  cases  medical  aid  is  first  sought  when 
renal  colic  appears.  The  only  medical  aid  possible  is  to  relieve 
the  pain  by  hypodermics  of  morphine  or  inhalations  of  chloro- 
form. Hot  applications  to  the  abdomen  and  warm  baths  may 
give  momentary  relief,  but  unless  the  calculus  is  small  and 
passes  readily  and  rapidly  through  the  ureters,  the  narcotics 
are  indispensable.  Morphine  can  be  given  in  1/4-grain  doses 
combined  with  1/100  grain  of  atropine.  Hematuria  is  rarely 
severe  enough  to  require  treatment.  If  pyuria  is  present  it 
must  be  treated  as  due  to  pyelitis.  When  surgical  intervention 
is  necessary  the  character  of  the  operation  must  be  left  to  the 
surgeon. 


340  PATHOLOGICAL   OLD    AGE 


Vesical  Calculus 


Vesical  calculus  occurs  more  frequently  in  old  age  than  in 
earlier  life  and  mostly  in  men  who  have  a  hypertrophied  pros- 
tate. Many  cases  originate  as  a  renal  calculus  which  has 
passed  into  the  bladder,  either  as  gravel  without  colic,  or  as  a 
larger  concretion.  The  bladder  being  generally  dilated  in  the 
aged,  the  base  forms  a  pouch  behind  the  enlarged  prostate  and 
the  gravel,  or  stone,  drops  into  this  pouch  and  forms  the  nucleus 
for  the  vesical  stone.  The  structure  is  the  same  as  in  renal 
calculus,  mucus  supplying  the  albuminous  material  for  the 
framework  and  the  decomposing  urine  furnishing  the  ammonia 
which  combines  with  the  earthy  phosphates,  the  latter  being 
precipitated  in  alkaline  urine.  The  nucleus,  if  coming  from  the 
kidney,  is  usually  a  small  uric  acid  calculus;  when  originating 
in  the  bladder,  it  may  be  any  constituent  of  the  urine  which  is 
liable  to  be  precipitated  in  an  insoluble  form,  or  else  it  is  epithe- 
lial debris,  fibrin,  cystin,  etc.  It  has  been  suggested  that  micro- 
organisms are  responsible  for  vesical  and  renal  calculi  but  these 
appear  to  cause  only  urinary  decomposition  with  production 
of  ammonia.  The  production  of  calculi  is  simply  the  result  of 
chemical  and  mechanical  processes  and  of  a  pathological  separa- 
tion of  albuminous  matter  from  the  mucus  which  forms  the 
framework  of  the  stone. 

Symptoms. — The  passage  of  a  renal  calculus  with  the  attend- 
ing renal  colic  and  the  certainty  that  the  stone  had  not  passed 
through  the  urethra  is  conclusive  evidence  of  the  presence  of  a 
calculus  in  the  bladder.  A  calculus  which  produces  colic  when 
passing  through  the  ureter  will  also  cause  intense  pain  when 
passing  through  the  urethra.  The  symptoms  of  vesical  calculus 
in  the  aged  when  the  stone  is  lodged  at  the  base  of  the  bladder 
behind  a  hypertrophied  prostate,  are  often  so  vague  that  a 
positive  diagnosis  cannot  be  made  without  instrumental 
examination  or  radiography.  The  pathognomonic  symptom 
of  vesical  calculus  in  earlier  life,  a  sudden  blocking  of  the 
urethra  while  urinating,  does  not  appear  when  the  stone  lies 
behind,  the  prostate.  In  most  cases  there  is  a  dull  ache  in  the 
perineum,  aggravated  by  jolting,  long  marches  or  any  motion 
which  would  disturb  the  stone.  Prolonged  sitting  which  ag- 
gravates the  ache  of  an  enlarged  prostate  has  no  such    effect 


VESICAL  CALCULUS  341 

upon  a  vesical  calculus.  Hematuria  may  be  present  and  this 
symptom  will  simulate  acute  cystitis.  In  the  latter  disease 
there  are  vesical  and  rectal  tenesmus  and  frequent  urination, 
the  urine  is  mixed  with  mucus,  pus,  and  epithelium,  all  of  which 
are  mild  or  absent  in  vesical  calculus.  The  stone  can  sometimes 
be  felt  by  the  finger  through  the  rectum,  its  hard  consistency 
distinguishing  it  from  growths  and  a  hypertrophied  prostate. 
Vesical  exploration  by  means  of  a  metallic  sound  and  of  a  cysto- 
scope  gives  the  most  certain  information  but  in  hypertrophied 
prostate  it  is  sometimes  difficult  to  so  manipulate  the  instru- 
ments as  to  bring  the  portion  of  the  bladder  situated  behind 
the  prostate  within  view  or  touch.  In  rare  cases  the  stone  may 
be  imbedded  in  one  of  the  vesical  pouches  and  the  pain  will  then 
be  located  over  the  location  of  the  stone.  In  such  case  the 
stone  will  produce  a  chronic  cystitis  but  unless  it  is  dislodged  by 
a  jolt  a  positive  diagnosis  can  be  made  only  by  instrumental 
exploration  or  X-ray.  When  the  sound  and  cystoscope  fail  to 
reveal  the  presence  of  a  stone  and  there  is  any  difficulty  in 
reaching  all  parts  of  the  viscus,  a  radiograph  is  necessary  to 
clear  up  the  diagnosis.  This  course  is  better  than  to  place 
the  patient  under  an  anesthetic  and  subject  him  to  rough  ex- 
ploratory instrumental  manipulation. 

Treatment. — Internal  medication,  except  for  the  relief  of 
symptoms  and  the  prevention  of  urinary  decomposition,  is  use- 
less. Injection  into  the  bladder  of  a  very  weak  solution  of  di- 
lute hydrochloric  or  nitric  acid  has  been  advocated,  but  a  weak 
solution  has  no  effect  upon  phosphatic  stone,  while  a  stronger 
solution  will  produce  an  acute  cystitis.  We  must  remember 
that,  while  the  nucleus  may  be  a  uric  acid  concretion  from  the 
kidney,  the  vesical  deposit  almost  always  consists  of  phosphates 
and  the  uric  acid  solvents  are  ineffectual.  The  only  radical 
treatment  is  surgical,  the  preferable  operation  being  lithotrity. 
In  many  cases  where  an  operation  for  removal  of  stone  is  neces- 
sary, a  hypertrophied  prostate  can  be  removed  at  the  same 
time.  When  a  condition  exists  making  it  advisable  to  perform 
a  prostatectomy  at  the  same  time,  the  preferable  operation  is 
the  suprapubic  cystotomy  advocated  by  Lilienthal.  This 
should  be  performed  under  local  anesthesia. 

In  the  ordinary  chronic  cystitis  the  primary  cause,  if  per- 
sistent, must  be  removed.     If  this  cannot  be  done,  measures 


342 


PATHOLOGICAL    OLD   AGE 


to  correct  decomposition  of  the  urine  and  irritability  of  the 
bladder  must  be  employed  and  continued.  After  the  turbidity 
has  cleared  up  salol  should  be  used  in  small  doses,  i  grain  two 
or  three  times  a  day,  to  prevent  its  return.  Irrigation  is  useful 
where  there  is  pus  or  persistent  mucus  in  the  urine.  If  pus  is 
present  the  silver  salts  are  preferable  but  if  there  is  only  mucus, 
sodium  borate  and  sodium  sulphite  should  be  used  in  the  propor- 
tion of  i  dram  to  4  ounces  of  warm  water  once  daily.  Hot 
applications  over  the  bladder  and  hot  enemata  will  usually 
relieve  the  pain  which  is  rarely  severe  unless  there  is  ulceration. 
Hyoscyamus  in  5 -minim  doses  of  the  fluid  extract  is  probably 
the  most  effective  drug  to  relieve  pain  and  irritability  in  these 
cases. 

Acute  cystitis  is  infrequent  in  the  aged,  except  as  a  mild 
infection  occasioned  by  the  introduction  of  a  dirty  catheter  or 
a  non-sterile  irrigating  liquid,  while  a  mild  irritation  may  be 
produced  by  some  irritating  abnormal  ingredient  of  the  urine. 
In  either  case  it  soon  becomes  chronic.  An  active  acute  inflam- 
mation is  extremely  rare  and  does  not  differ  from  the  same 
disease  in  maturity. 

SENILE  METRORRHAGIA 

Metrorrhagia  is  a  symptom  of  various  uterine  disorders. 
Occurring  during  the  menopause  it  is  usually  the  menstrual 
flow  coming  on  at  irregular  intervals.  It  may,  however,  be 
due  to  an  endometritis,  prolapsed  uterus  or  to  a  growth. 
Endometritis  and  prolapse  give  clearly  defined  symptoms 
and  the  metrorrhagia  accompanying  these  conditions  is  readily 
controlled  by  styptics.  Metrorrhagia  due  to  fibroids,  polyps 
or  cancer  is  more  persistent  and  continues  after  the  completion 
of  the  menopause.  In  the  case  of  fibroids  the  flow  usually  di- 
minishes as  the  senile  involution  of  the  organ  proceeds  and  it 
may  cease  completely.  Polyps  usually  have  a  copious  flow 
coming  on  in  spurts  or  there  may  be  a  continous  dribble.  It 
generally  diminishes  during  the  menopause  and  may  cease 
altogether.  The  flow  that  accompanies  malignant  disease 
begins  as  an  insignificant  watery,  scanty  discharge  having  a 
pinkish  tinge  and  slight  or  no  odor.  This  discharge  may 
exist  for  months  before  any  attention  is  paid  to  it.     It  gradually 


Spondylitis  Deformans.     Regular  Contour.     X-ray  shows  ossification  of  in- 
ter vertebral  articulations.     (Courtesy  of  S.  Epstein,  M.  D.,  New  York.  I 


SENILE  METRORRHAGIA  343 

becomes  darker  and  more  copious  and  begins  to  have  a  fetid 
odor,  which  increases  in  intensity  until  it  becomes  intolerable. 
When  this  condition  is  reached  the  only  question  of  diagnosis  is 
between  cancer  and  senile  metritis  (see  Senile  Metritis).  In 
the  early  stage  the  effect  of  local  treatment  will  usually  suffice 
to  distinguish  the  metrorrhagia  of  malignant  disease  from 
other  forms  of  metrorrhagia.  The  discharge  due  to  malignant 
disease  will  persist  in  spite  of  the  use  of  styptics  and  astringents, 
their  action  lasting  but  a  few  minutes  or  hours.  In  other  forms 
of  metrorrhagia  the  flow  is  controlled  temporarily  and  often 
permanently  under  local  treatment. 

A  metrorrhagia  beginning  after  the  completion  of  the  meno- 
pause is  almost  invariably  due  to  malignant  disease.  Other 
causes  are  the  hemorrhagic  form  of  senile  metritis,  cardiac  dis- 
ease and  traumatism,  but  these  are  extremely  rare.  The  metror- 
rhagia in  malignant  disease  sometimes  begins  as  a  scanty,  thin, 
yellowish  discharge,  slowly  becoming  pinkish  then  darker  until 
it  is  dark  red  or,  if  mixed  with  pus,  a  dirty  red.  At  the  same 
time  it  becomes  thicker,  more  copious  and  continuous  and 
assumes  a  fetid  odor.  In  some  of  these  cases  the  discharge  is 
yellowish  or  grayish  and  contains  drops  or  streaks  of  blood.  In 
other  cases  the  discharge  is  slight  for  a  time,  suddenly  becoming 
copious  or  appearing  abundantly  for  a  few  hours  then  dimin- 
ishing again,  these  gushes  coming  on  at  irregular  intervals. 
It  is  hardly  necessary  here  to  give  the  other  symptoms  and  signs 
of  uterine  cancer.  The  pain,  sensitiveness  on  pressure,  enlarge- 
ment of  the  organ  and  general  cachexia,  all  point  to  malignant 
disease,  but  the  diagnosis  must  be  confirmed  by  an  examina- 
tion of  a  curette  scraping. 

The  treatment  of  senile  metrorrhagia  depends  upon  its  cause. 
If  it  is  simply  an  irregular  menstrual  flow  nothing  need  be  done, 
but  absolute  rest  may  be  necessary.  Astringent  solutions  will 
generally  avail  in  the  case  of  endometritis  and  prolapse.  These, 
and  ergot  internally  in  1/2-dram  doses,  will  generally  tempor- 
arily control  the  loss  of  blood  from  fibroids  and  polyps ;  surgical 
intervention,  however,  may  be  necessary  to  remove  the  cause. 
In  all  cases  where  there  is  an  exhausting  loss,  hot  douches 
should  be  given  and  if  these  do  not  suffice  to  control  the  flow 
astringents  like  tannic  acid,  perchloride  of  iron  or  zinc  sulphate 
should  be  added.     As  a  last  resort  packing  of  the  uterus  may 


344  PATHOLOGICAL   OLD    AGE 

be  tried  but  occasions  for  this  are  extremely  rare.  The  most 
effective  means  to  destroy  the  fetor  of  cancerous  discharges  is  a 
douche  containing  a  tablespoonful  of  a  3 -per  cent,  solution  of 
permanganate  of  potash  to  a  pint  of  water.  Hot  douches  have 
no  effect  in  controlling  hemorrhage  in  uterine  cancer.  If  hemor- 
rhage occurs,  powerful  astringents,  such  as  Monsell's  solution 
diluted  1  to  8,  or  the  sulphate  of  iron  and  ammonium  in  10-per 
cent,  solution,  will  be  required.  The  effect  is,  however,  only  tem- 
porary and  the  cure  will  depend  upon  the  cure  of  the  causative 
condition. 

CHRONIC  RHEUMATISM 

This  is  a  primary  disease  of  middle  and  advanced  age  which, 
in  its  pathology,  resembles  the  changes  of  senile  arthrosclerosis. 

Etiology. — In  some  cases  there  is  a  history  of  earlier  attacks 
of  acute  articular  or  subacute  rheumatism,  but  only  in  rare 
instances  has  either  of  these  diseases  immediately  preceded 
chronic  rheumatism.  The  basic  etiological  factor  is  unknown, 
but  it  occurs  most  frequently  in  those  who  are  much  exposed  to 
cold  and  dampness  and  who  are  generally  weakened  by  im- 
proper living  and  hard  work.  The  disease  is  probably  but  a 
perversion  of  the  ordinary  senile  processes  in  the  joints  brought 
on  earlier  than  usual  through  some  local  causes. 

Pathology. — The  most  marked  anatomical  changes  are 
found  in  the  articular  cartilages  which  become  roughened;  and 
in  the  ligaments  and  tendons,  which  become  thickened  and 
hardened.  The  synovial  membrane  also  thickens  and  the  syno- 
vial fluid  is  usually  diminished  in  quantity.  The  muscles  atro- 
phy from  disuse  and  there  are  often  evidences  of  senile  changes 
in  other  tissues. 

Symptoms. — The  disease  is  slowly  progressive  with  occa- 
sional acute  exacerbations  and  often  "with  long  periods  of  remis- 
sion. It  begins  as  a  dull  ache  in  the  affected  joints,  generally 
in  the  evening  after  the  joints  have  been  actively  used  during 
the  day.  They  feel  stiff  and  sore  and  may  be  swollen.  The 
stiffness  persists  throughout  the  night  and  is  relieved  after 
slight  active  motion  in  the  morning.  Slowly  and  gradually  the 
stiffness  increases  until  finally  the  joint  is  completely  and  per- 
manently anchylosed.     It  may  take  many  years  after  the  initial 


CHRONIC  RHEUMATISM  345 

symptoms  appear  before  the  final  result  is  reached.  Exacer- 
bations with  increased  stiffness,  pain  and  swelling,  which  lasts 
for  several  days,  will  occasionally  occur.  The  joints  most  fre- 
quently affected  are  those  most  frequently  used  or  exposed  to 
deleterious  influences,  i.e.,  the  hands  of  manual  laborers  and 
the  feet  of  those  who  walk  much.  In  many  cases  one  hand  or 
one  foot  alone  or  a  hand  and  a  foot  on  the  same  side  are  af- 
fected. The  large  joints  are  seldom  involved.  The  disease  is 
frequently  associated  with  senile  changes  in  other  tissues  and 
these  contribute  their  symptoms  to  the  symptoms  of  the 
disease. 

Diagnosis. — In  the  early  stage  of  the  disease  it  must  be 
differentiated  from  the  early  stage  of  arthritis  deformans  and 
from  senile  arthrosclerosis.  In  multiple  arthritis  deformans  a 
number  of  joints  are  affected  and  the  disease  is  bilateral,  os- 
teophytes appear  and  the  flexors  are  contracted.  It  is  impos- 
sible to  distinguish  between  chronic  rheumatism  and  arthri- 
tis deformans  in  an  early  stage  when  only  a  single  large  joint 
is  involved.  Later,  the  presence  or  absence  of  flexion  and 
deformity  will  determine  the  diagnosis.  It  is  also  important 
to  differentiate  between  chronic  rheumatism  and  arthrosclerosis 
and  this  can  be  determined  by  a  single  symptom.  The  pain  and 
stiffness  of  the  joint  in  chronic  rheumatism  are  relieved  after 
limbering  up  in  the  morning,  while  in  arthrosclerosis  there  is 
no  pain  during  rest  and  motion  produces  more  and  more  pain. 
In  gout  a  single  joint  is  affected  and  there  are  paroxysmal 
attacks  coming  on  at  night.  In  gonorrheal  rheumatism  there 
is  the  history,  the  symptoms  are  more  active  and  the  disease 
is  rare  in  the  aged.  Progressive  muscular  atrophy  has  been 
mistaken  for  chronic  rheumatism,  but  in  that  disease  there  is 
little  or  no  pain.  The  difficulty  of  motion  in  these  cases  is 
due  to  waste  of  muscle  and  not  to  joint  stiffness,  the  apparent 
enlargement  of  the  joints  being  due  to  the  retraction  of  the 
wasted  muscles. 

Treatment. — Permanent  arrest  of  the  disease  has  followed  a 
complete  change  in  the  mode  of  life  of  the  patient  with  avoid- 
ance of  exposure  to  cold  and  wet  and  residence  in  a  dry  warm 
climate.  The  iodides  are  sometimes  beneficial,  but  more  lasting 
results  have  followed  hydrotherapy,  electrotherapy  and  ther- 
motherapy.     In   some  cases  hot  applications,   in  others    cold 


346  PATHOLOGICAL    OLD   AGE 

applications  seem  to  do  better.  The  "baking"  process  has 
been  followed  by  permanent  relief  and  cures  have  been  reported 
from  the  use  of  the  high-frequency  current.  Massage  and 
vibration  frequently  relieve  the  stiffness  and  have  been  found 
of  temporary  benefit  even  after  complete  anchylosis.  General 
tonics  must  be  employed  and  for  this  purpose  nothing  equals 
phosphorus  and  arsenic. 

ARTHRITIS  DEFORMANS 

This  disease,  often  erroneously  called  chronic  rheumatism, 
is  a  primary  progressive  disease  of  the  joints  occurring  during 
or  after  middle  life. 

Etiology. — The  basic  cause  is  uncertain.  Two  general 
theories  are  held,  (i)  that  it  is  of  nervous  origin  and  (2)  that  it 
is  a  bacterial  disease.  Poncet  claims  it  to  be  a  tubercular  affec- 
tion of  the  joints,  and  Valentine  found  that  40  per  cent,  of  cases 
of  arthritis  deformans  had  tuberculosis.  The  bacterial  theory 
is  based  upon  the  fact  that  microorganisms  have  been  found 
in  the  joints  of  cases  that  began  with  acute  symptoms.  As 
the  disease  is  usually  insidious  in  its  advent,  it  is  probable 
that,  where  cases  begin  with  acute  symptoms,  those  symptoms 
belong  to  an  acute  infectious  disease,  perhaps  to  acute  articular 
rheumatism,  with  which  the  arthritis  deformans  has  nothing  in 
common  except  the  one  single  symptom  of  pain  in  the  joints. 
The  neurotic  theory  is  based  upon  (1)  the  similarity  of  the 
lesions  to  some  spinal-cord  lesions,  (2)  the  frequent  occurrence 
of  dystrophies,  (3)  the  influence  of  mental  disturbances  and 
emotions  in  its  causation.  Each  of  these  can  be  controverted 
by  the  simple  fact  that  they  do  not  apply  to  the  majority  of 
cases.  Damsch  offers  a  toxin  theory.  Ord  advances  a  theory 
that  the  disease  is  due  to  a  lesion  in  the  trophic  centers  of  the 
cord.  A  further  study  of  this  disease,  however,  shows  that 
the  anatomical  changes  are  identical  with  the  normal  senile 
joint  changes,  but  they  proceed  faster  and  are  carried  further 
than  in  senile  arthrosclerosis.  The  disease  begins  in  the  joints 
that  have  been  most  actively  employed,  generally  the  hands, 
followed  by  the  ankles  and  feet,  then  the  knees,  wrists,  elbows, 
shoulders,  cervical  spine,  hips  and  lastly  the  dorsal  spine. 
The  flexor  muscles,   which   are   the   ones   that   are   the   most 


Spondylitis  Deformans 


Irregular  Contour.      Sideview. 
M.  I).,  New  York.) 


(Courtesy  of  S.  Epstein, 


ARTHRITIS  DEFORMANS  347 

actively  employed,  become  permanently  contracted,  thereby 
producing  the  deformities  which  are  pathognomonic  of  this 
disease.  From  these  facts  it  would  seem  that  the  disease  is 
but  an  early  and  exaggerated  senile  process.  The  pains  are 
due  to  degeneration  of  the  nerve  terminals  in  the  affected 
tissues. 

The  exciting  causes  are  unknown.  Every  conceivable 
departure  from  a  natural  mode  of  life — the  excessive  use  of 
amylaceous  and  saccharine  food,  exposure,  exhaustion,  sexual 
excesses,  unhygienic  surroundings,  rapid  temperature  changes, 
etc.,  have  been  cited  as  possible  exciting  causes. 

Pathology. — The  articular  cartilages  become  dry,  fibril- 
lated  and  wear  away  through  attrition,  leaving  the  bone  exposed. 
The  spongy  portion  of  the  bone  wastes,  the  articular  surfaces 
roughen  and  eburnation  ensues  as  the  result  of  friction.  Osseous 
nodules,  or  a  complete  osseous  ring  may  form  about  the  articu- 
lating surface.  The  synovial  membrane  thickens  and  the  sac 
becomes  dry.  Thickening  and  hardening  of  the  ligaments  and 
tendons  and  waste  of  the  muscles  contribute  to  the  anatomical 
changes  which  cause  the  characteristic  deformities  marking  the 
disease. 

Symptoms. — The  disease  appears  in  three  forms,  complete 
or  multiple,  partial,  and  abortive. 

The  multiple  form  is  the  most  frequent,  and  usually  begins 
as  a  dull  ache  in  a  single  joint  of  a  finger  or  toe  which  later 
becomes  swollen  and  painful  to  the  touch  or  upon  motion, 
while  the  joint  becomes  flexed.  In  the  meantime  the  corre- 
sponding joint  on  the  other  side  becomes  affected.  The  affec- 
tion spreads  to  other  joints  of  the  hand  or  foot  and  to  the  corre- 
sponding joints  on  the  opposite  side.  The  effusion  is  slight, 
never  as  extensive  as  in  acute  articular  rheumatism,  nor  is  the 
pain  in  the  early  stage  of  the  disease  severe.  There  may, 
however,  be  neuralgic  pains,  or  the  more  persistent  pains  of 
neuritis,  due  to  irritation  or  degeneration  of  the  nerve  ter- 
minals in  the  affected  tissues.  The  disease  is  progressive,  with 
frequent  remissions,  the  relapses  being  generally  more  severe 
than  the  previous  attacks  and  increasing  the  deformities.  In 
an  advanced  stage  of  the  disease  the  fingers  turn  toward  the 
ulnar  side,  are  flexed  and  may  overlap.  The  wrists  turn  out- 
ward, the  elbows  are  bent,  the  shoulders  are  fixed,  with  the 


348  PATHOLOGICAL    OLD    AGE 

arms  hanging  down  and  the  hips  and  knees  are  flexed.  The 
amount  of  rigidity  in  different  joints  may  vary,  but  the  corre- 
sponding joints  of  the  two  sides  are  generally  affected  to  the 
same  extent. 

Complete  anchylosis  is  rare,  true  bony  anchylosis  occurring 
only  in  the  spinal  column.  A  famous  example  of  complete 
rigidity  of  the  joints  was  "the  ossified  man,"  who  was  on  public 
exhibition  for  many  years.  Various  skin  disorders  occasion- 
ally appear  in  connection  with  the  disease.  There  may  be 
pigmentation,  bromidrosis,  or  local  sweating,  paresthesias,  etc. 

The  acute  form  of  rheumatic  arthritis,  which  begins  with 
symptoms  resembling  an  acute  articular  rheumatism,  does  not 
occur  in  old  age. 

The  partial  form,  also  called  the  monarticular  type  is  con- 
fined principally  to  one,  or  a  few  of  the  larger  joints,  while  the 
smaller  joints  either  escape  entirely,  or  are  but  slightly  affected. 
There  is  the  same  train  of  symptoms,  beginning  with  tenderness, 
then  effusion  and  pain  with  remissions  and  exacerbations, 
gradual  stiffening  of  the  joint,  and  deformity. 

Morbus  coxcb  senilis  is  a  form  of  partial  arthritis  deformans 
in  which  one  hip,  or,  rarely,  both  hips  are  affected.  The 
capsular  ligament  and  ligamentum  teres  contract  and  other 
joint  changes  take  place.  The  leg  is  apparently  shortened  and 
gradually  becomes  fixed  in  a  bent  position. 

Spondylitis  deformans  is  a  rheumatic  arthritis  confined  to 
the  spinal  column.  It  occasionally  terminates  in  complete 
bony  anchylosis.  The  abortive  form  of  arthritis  deformans 
usually  begins  in  the  distal  joints  of  the  fingers  but  rarely  passes 
beyond  them,  though  it  may  affect  the  toes.  It  is  marked  by 
the  production  of  exostoses,  called  "Heberden's  Nodes,"  rang- 
ing in  size  from  a  pin's  head  to  a  pea,  which  form  on  the  sides 
and  ends  of  the  distal  joints  of  the  fingers.  The  changes  in  the 
joints  are  the  same  as  in  other  types,  but  there  is  rarely  a  con- 
traction of  the  flexor  tendons  or  waste  of  muscle.  In  some 
cases  the  presence  of  the  nodes  is  the  only  symptom. 

Diagnosis. — In  the  early  stage  of  arthritis  deformans  it  is 
often  difficult  to  distinguish  it  from  other  arthritic  diseases. 
The  acute  form  of  the  multiple  type  resembles,  in  its  onset,  acute 
or  subacute  articular  rheumatism,  but  this  form  does  not  occur 
in  the  aged.     The  slow  insidious  advent,  the  absence  of  fever, 


ARTHRITIS  DEFORMANS  349 

the  involvement  of  the  small  joints,  and  the  stationary  character 
of  the  anatomical  changes  in  the  beginning  of  the  disease  will 
distinguish  it  from  subacute  rheumatism.  Crepitation  upon 
motion  which  is  appreciable  to  a  delicate  touch,  is  often  an  early 
symptom  of  rheumatic  arthritis.  This  is  absent  in  subacute 
and  chronic  rheumatism.  Chronic  rheumatism  is  generally 
unilateral,  and  the  affected  joints  are  usually  stiff  and  painful 
after  prolonged  rest.  The  stiffness  and  pain  are  diminished 
after  motion,  whereas  motion  increases  the  pain  of  rheumatic 
arthritis,  resembling,  in  this  respect,  senile  arthrosclerosis. 

Gout  attacks  a  single  joint,  generally  of  the  big  toe,  the 
attack  is  paroxysmal,  comes  on  at  night  and  is  much  more  severe 
than  the  attack  of  rheumatic  arthritis. 

Other  arthritic  diseases  can  be  eliminated  by  the  age,  his- 
tory, or  by  pathognomonic  symptoms. 

Treatment. — The  disease  is  progressive,  but  the  attacks  of 
swelling  and  pain  become  gradually  less  frequent  and  less 
painful,  while  the  rigidity  proceeds  until  the  patient  is  bed- 
ridden. The  disease  is  incurable  and,  while  temporary  relief 
can  be  afforded  during  the  acute  exacerbations,  no  method  of 
treatment  has  given  permanent  results.  Drug  treatment  is 
useless  except  to  relieve  pain,  when  the  salicylates  or  opiates 
may  be  given.  Of  the  non-medicinal  measures,  hydrotherapy, 
electrotherapy,  mechanotherapy  and  thermotherapy  have  been 
employed  in  various  forms,  some  cases  being  temporarily  relieved 
by  one  form  of  treatment,  while  in  other  cases  the  progress  was 
apparently  hastened.  The  most  that  can  be  expected  from 
them  is  a  prolonged  remission  with  temporary  lessened  rigidity 
of  the  joints.  In  one  case  treatment  at  the  hot  sulphur  springs 
at  Aix  la  Bains  was  followed  by  a  remission  lasting  two  years. 
Hot  baths  and  fomentations  give  temporary  relief.  The  high- 
frequency  current  has  been  found  beneficial  in  some  cases  and 
reports  of  apparent  cure  have  followed  the  use  of  the  X-ray  with 
massage.  Favorable  reports  have  come  from  the  hot-air  treat- 
ment and  Bier's  hyperemia  treatment. 

Temporary  relief  from  the  deformity  of  the  hands  was 
obtained  in  one  instance  by  immersing  them  in  hot  water  for 
half  an  hour,  then  forcibly  extending  the  fingers.  The  fingers 
remained  extended  for  several  days  and  motion  was  possible, 
but  they  soon  began  to  resume  their  flexed  position. 


350  PATHOLOGICAL   OLD   AGE 

Of  hygienic  measures,  mild  exercise  and  the  prevention 
of  mental  depression  caused  by  the  ill  success  of  treatment  are  the 
most  important.  Gentle  exercise  is  necessary,  but  fatigue 
should  be  avoided.  Active  exercise  of  the  affected  joint  hastens 
the  pathological  changes,  while  no  exercise  will  cause  waste  of 
muscle  from  non-use.  Of  psychic  measures,  change  of  sur- 
roundings and  scene  is  the  most  important.  The  benefits 
derived  from  a  trip  to  a  watering  place,  or  to  medicinal  springs 
are  attributable,  in  great  measure,  to  the  change  of  surroundings, 
for  the  same  mineral  waters  taken  at  home  do  not  produce  the 
same  results.  Other  hygienic  measures,  such  as  a  dry  equable 
climate,  the  avoidance  of  surface  chilling,  nutritious  dieting, 
etc.,  are  self  understood. 

PAGET'S  DISEASE 

Etiology. — This  rare  disease  of  the  bones  occurs  almost 
exclusively  in  advanced  age.  It  consists  of  an  increase  in  the 
volume  of  bone  as  seen  in  acromegaly  and  a  softening  of  bone 
as  in  osteomalacia  and  it  is  supposed  that  the  same  causes 
producing  these  conditions,  namely,  disease  of  the  hypophysis 
and  of  the  thyroid,  are  responsible  for  the  trophic  changes  in 
Paget's  disease  also.  Numerous  other  causes,  such  as  fatigue, 
exposure  to  cold  or  wet,  traumatism,  syphilis,  cancer,  etc., 
have  been  suggested.  Some  observers  found  spinal  lesions  in 
their  cases,  others  failed  to  find  any,  but  arteriosclerosis  of  the 
vessels  supplying  the  affected  bones  is  found  in  almost  every 
case. 

Pathology. — The  anatomical  changes  in  Paget's  disease 
consist  of  waste  of  bone  tissue  in  some  places  and  hyperplasia 
in  others.  The  Haversian  canals  in  some  localities  are  enlarged, 
in  others,  obliterated.  There  is  no  uniformity  in  location, 
degree  or  extent  of  these  changes  and  all  the  bones  may  be 
affected,  but  the  most  pronounced  changes  are  found  in  the 
tibiae  and  femurs.  Owing  to  the  softening  of  these  bones  and 
to  the  downward  pressure  of  the  body  upon  them,  they  become 
curved,  and  the  neck  and  shaft  of  the  femur  form  a  right  angle. 
The  marrow  is  very  vascular  and  the  periosteum  is  thickened. 

Symptoms. — The  onset  of  the  disease  is  insidious,  often 
unnoticed  until  a  change  in  the  shape  of  the  bone  is  observed. 


Spondylitis  Deformans. 


Irregular  Contour.     Backview. 
M.  D.,  New  York.) 


(Courtesy  of  S.   Epstein, 


GOUT  351 

In  some  cases  there  are  vague  pains  and  aches  as  in  chronic 
rheumatism,  occasionally  there  are  paroxysmal  sharp  pains 
in  the  affected  bones.  Pain  is  sometimes  present  throughout 
the  disease,  in  some  cases  aggravated  upon  walking,  in  some 
cases  coming  on  in  paroxysms,  in  other  cases  absent.  When 
the  spinal  column  is  pressed  upon,  as  may  occur  in  the  deformity 
that  accompanies  spinal  osteitis  deformans,  or  when  a  nerve 
is  compressed  the  pain  becomes  increasingly  severe.  The  most 
important  symptoms  are  thickening  and  malformation  of  the 
bones,  the  character  and  extent  of  deformity  depending  upon 
the  location  of  the  affected  bones  and  the  amount  of  pressure 
to  which  they  are  subjected.  For  this  reason  the  spine  and 
lower  extremities  are  most  deformed,  the  increased  curvature 
of  the  spine  producing  a  change  in  the  shape  of  the  thorax. 

The  only  disease  which  bears  any  marked  resemblance  to 
Paget's  disease  is  osteomalacia,  which  is  very  rare  in  the  aged. 
In  osteomalacia  all  the  bones  of  the  body  are  affected,  the 
curvature  of  the  spine  is  very  marked  and  the  pelvis  is  deformed, 
while  in  Paget's  disease  the  deformity  is  usually  confined  to  the 
lower  extremities.  Pain  is  usually  pronounced  in  osteomalacia 
and  generally  absent  in  Paget's  disease.  The  bones  are  not 
increased  in  size  in  osteomalacia.  Acromegaly  is  extremely 
rare  after  the  sixtieth  year  and  it  does  not  affect  the  extremities. 

The  disease  is  incurable  but  it  may  last  for  ten  or  fifteen 
years  before  an  intercurrent  disease,  generally  bronchopneu- 
monia, causes  death. 

There  is  no  known  method  of  treatment  and  the  only 
thing  that  can  be  done  is  to  treat  the  distressing  symptoms. 
Phosphorus  has  been  found  of  benefit  in  osteomalacia  and  it 
may  relieve  symptoms  of  Paget's  disease,  but  no  cure  has  yet 
been  effected. 

(Pseudo-Paget's  disease  is  included  under  the  first  group.) 

GOUT 

' '  Gout  is  a  clinical  syndrome  arising  from  defective  assimi- 
lation of  nitrogenized  substances."1 

Numerous  theories  have  been  advanced  to  explain  the  patho- 
genesis and  nature  of  gout  but  no  one  is  free  from  unanswerable 

1Rathery,  "Manuel  des  Maladies  de  la  Nutrition." 


352  PATHOLOGICAL   OLD   AGE 

criticism.  Biurate  of  soda  is  deposited  in  the  joints,  but  the 
origin  of  the  uric  acid  is  uncertain,  some  investigators  believing 
it  to  be  a  product  of  incomplete  metabolism,  some  think  it  a 
product  of  perverted  metabolism,  while  others  say  it  is  the 
product  of  complete  metabolism  of  purin-forming  substances. 
Garrod's  theory  that  uric  acid  is  retained  in  the  blood  instead  of 
being  eliminated  by  the  kidneys  has  now  few  supporters.  He 
placed  the  primary  fault  into  the  kidneys.  Another  theory  ex- 
plains gout  as  due  to  a  hyperproduction  of  uric  acid,  a  minute 
quantity  being  normal  to  the  individual.  Ord  ascribes  the  source 
of  this  hyperproduction  to  the  products  of  degeneration  of  certain 
fibrous  tissue;  Murchison  claims  it  to  be  a  functional  perversion 
of  the  liver  whereby  albuminoid  material  is  converted  into  uric 
acid  instead  of  into  urea;  Ebstein  believes  that  the  sources  of 
normal  production  of  uric  acid  are  multiplied  in  gout.  Another 
theory  is  that  uric  acid  and  the  purins  are  not  completely  con- 
verted or  destroyed  owing  to  deficiency  of  deoxidizing  ferments 
(oxydases)  in  the  blood.  Other  theories  ascribe  the  presence  of 
an  excessive  amount  of  uric  acid  in  the  circulation  to  the  changed 
condition  of  the  blood,  a  uric-acid  dyscrasia,  the  diminished 
alkalinity  causing  incomplete  oxidation;  others  claim  that  in- 
creased alkalinity  makes  the  blood  a  poorer  solvent,  therefore, 
a  larger  quantity  of  uric  acid  is  thrown  from  its  solution  and  de- 
posited in  the  tissues,  again  that  the  tissues  in  which  the  biurate 
of  soda  is  deposited  are  less  alkaline  than  the  blood,  some  think 
that  where  the  circulation  is  slowest  the  salt  is  deposited,  and 
finally,  that  certain  tissues  have  an  affinity  for  this  salt.  Other 
theories  are  based  upon  the  chemical  changes  by  which  the 
biurate  of  soda  is  produced;  that  uric  acid  and  thyminic  acid 
are  formed  together  from  the  nucleins  and  are  in  combination 
and  that  in  gout  more  uric  acid  is  formed;  or  that  uric  acid  is 
derived  from  substances  that  do  not  form  the  thyminic  acid, 
or  that  uric  acid  is  precipitated  as  an  insoluble  biurate  in  the 
presence  of  glycocoll,  or  that  the  urates  exist  in  two  forms,  a 
stable  and  but  slightly  soluble  one  and  an  instable  and  readily 
soluble  one,  that  the  latter  is  converted  into  the  former,  etc. 
The  latest  theory  is  that  uric  acid  is  produced  in  excess  from 
certain  proteids  containing  purin-forming  bases  and  that  it  is  the 
end  result  of  the  metabolism  of  such  purins.  Another  theory 
which  has  many  supporters  ascribes  gout  to  a  faulty  metabolism 


gout  353 

of  proteids  through  failure  of  the  nervous  system  to  properly 
regulate  the  process  of  metabolism. 

These  are  but  few  of  the  many  theories  that  have  been  ad- 
vanced to  explain  the  pathogenesis  and  nature  of  gout.  There 
are  arguments  which  cannot  be  controverted  in  some  cases, 
while  in  other  cases  they  are  completely  refuted. 

Etiology. — In  most  cases  there  is  an  inherited  gouty  diathesis. 
In  some  there  is  another  disorder  of  metabolism  such  as  obesity, 
diabetes,  etc.,  giving  symptoms  of  gout  in  addition  to  its  own 
symptoms  and  the  disappearance  of  the  other  disorder  relieves 
the  symptoms  of  gout. 

It  is  most  frequently  found  in  those  using  fermented  liquors 
and  in  countries  where  wines,  heavy  beers  and  ales  are  consumed 
in  large  quantities.  Its  frequency  among  those  who  drink  such 
liquors,  and  its  rarity  among  drinkers  of  distilled  liquors  would 
seem  to  point  to  a  fermentation  product  and  not  to  the  alcohol 
as  the  etiological  factor  in  these  cases.  This  would  also  explain 
the  increase  of  the  disease  in  America,  keeping  pace  with  the  in- 
crease in  the  consumption  of  beer.  It  is  probable  that  its  fre- 
quency among  lead  workers,  type  founders,  painters,  etc.,  is 
due  to  the  large  quantities  of  beer  and  ale  consumed  by  them 
to  quench  the  intolerable  thirst  of  chronic  plumbism.  In  many 
cases  of  chronic  lead,  zinc  or  mercury  poisoning  or  where  opium, 
belladonna,  iodides  or  nitrites  have  been  used,  there  is  more  or 
less  suppression  of  the  secretions,  with  consequent  excessive 
thirst,  which  is  often  quenched  by  alcoholic,  or,  more  especially, 
fermented  liquors.  This  will  account  for  the  frequent  attacks 
of  gout  in  such  conditions.  It  may  be,  too,  that  these  toxins 
interfere  with  metabolism  and  if  combined  with  a  gouty  diathesis 
an  attack  will  be  produced. 

Rich,  highly  seasoned  food  in  an  excessive  amount  is  an  eti- 
ological factor,  such  food  being  also  rich  in  purin-forming  mate- 
rial. Gout,  however,  often  attacks  those  who  are  insufficiently 
nourished  and  the  so-called  poor  man's  gout  does  not  differ 
from  the  gout  of  those  who  live  idle  lives,  eat  rich  food  and  drink 
heavy  wines.  While  excesses  in  food  and  drink,  especially  of 
nitrogenized  foods  and  fermented  liquors,  are  the  principal  eti- 
ological factors,  yet  any  mental  strain,  sudden  emotion,  infectious 
disease,  traumatism,  excessive  venery,  or  fault  in  the  mode  of  life 
may  bring  on  an  attack  in  a  person  having  the  gouty  diathesis. 
23 


354  PATHOLOGICAL   OLD   AGE 

Pathology. — The  pathognomonic  lesion  is  a  deposit  of  bi- 
urate  of  soda  in  the  affected  joints.  This  begins  just  below  the 
free  surface  of  the  articular  cartilage  and  the  deposit  gradually 
increases,  invading  the  joint  structure  and  incrusting  the  carti- 
lage with  a  layer  of  sodium  biurate.  Later  the  tendons  become 
involved  and  a  salt  deposit  is  found  upon  them  and  sometimes 
upon  the  synovial  membrane.  The  synovial  fluid  becomes 
thickened  and  may  contain  crystals  of  the  salt.  The  salt  fre- 
quently collects  in  small  masses,  called  tophi,  which  surround 
the  joint  and  may  appear  on  the  tendons  a  short  distance  from 
the  joints.  Tophi  are  also  frequently  found  in  the  cartilage  of 
the  ear,  occasionally  in  the  cartilages  of  the  nose  and  other 
cartilaginous  structures,  but  rarely  in  muscle. 

During  an  acute  attack,  the  affected  joint  is  inflamed.  In 
most  cases  the  disease  begins  in  the  first  joint  of  the  big  toe, 
later  involving  the  ankles,  knees  and  lastly  the  joints  of  the  fingers. 
Occasionally  the  fingers  are  first  affected.  The  kidneys  are 
sometimes  involved,  showing  either  the  changes  of  nephritis  or 
biurate  of  soda  deposits. 

Varieties. — Many  forms  and  varieties  of  gout  have  been 
described,  all  can  be  placed  under  two  heads,  however,  i.e., 
regular  and  irregular  gout,  the  latter  usually  called  goutiness. 
Gout  is  a  chronic  condition,  every  case  being  chronic  from  its 
inception,  and  the  term  chronic  gout  in  contradistinction  to  other 
forms  of  gout  is  a  misnomer.  The  paroxysmal  attacks  called 
acute  gout  are  incidents  occurring  in  the  course  of  the  chronic 
disease,  and  cannot  be  considered  an  entity  apart  from  the 
chronic  condition  any  more  than  could  the  symptom-complex 
known  as  cardiac  asthma,  occurring  after  exertion  in  cardiac 
dilatation,  be  called  a  separate  disease.  Gout  rarely  begins  with 
an  acute  attack.  Premonitory  symptoms  showing  the  existence 
of  a  gouty  condition  usually  appear  days,  weeks  or  months  before 
the  acute  attack  and  there  is  almost  always  some  discoverable 
cause  for  it.  What  is  usually  described  as  acute  gout  will  be 
treated  here  as  an  acute  attack  of  regular  gout.  Irregular  or 
extra-articular  gout,  or  goutiness,  is  applied  to  a  number  of  ill- 
defined  pathological  lesions  or  functional  perversions  found  in 
persons  having  a  gouty  diathesis.  With  the  increase  of  gouti- 
ness there  is  an  increasing  tendency  to  ascribe  to  it  any  patho- 
logical condition  for  which  no  other  etiological  factor  can  be 


Paget's  Disease.  Nouvelle  Iconographie  de 
la  Salpetriere,  May-June,  1905. 


gout  355 

discovered.  This  variety  of  gout  presents  an  acute  phase,  the 
retrocedent  gout  which  immediately  follows  the  acute  attack  of 
regular  gout. 

Symptoms. — In  some  cases  of  regular  gout  there  are  no 
marked  symptoms  until  the  onset  of  the  acute  attack,  in  other 
cases  there  are  prodromal  symptoms  appearing  a  few  days 
before  the  attack,  while  in  some  there  are  various  functional 
impairments  with  occasional  twinges  in  the  small  joints  for 
weeks  or  months  before  an  attack  occurs.  Between  the  at- 
tacks, the  patient  may  feel  in  perfect  health,  or  there  may  be 
functional  impairments  (which  will  be  described  under  Irregular 
Gout)  or  twinges  in  the  affected  joints.  Usually  the  patient 
does  not  notice  the  prodromal  symptoms  of  the  first  attack, 
headache,  loss  of  appetite,  malaise  and  little  aches  and  twinges 
in  the  small  joints  of  the  toes,  and  occasionally  of  the  hands. 
Having  once  experienced  an  attack,  however,  he  will  quickly 
notice  these  premonitory  signs  and  there  will  be  restlessness 
and  depression  brought  on  by  the  anticipation  and  fear  of  the 
attack.  The  onset  is  ushered  in  with  an  intense  pain  coming 
on  suddenly  or  rapidly  and  generally  at  night,  and  in  most 
cases  involving  the  big  toe.  The  joint  becomes  red,  swollen, 
intensely  painful,  and  tender  to  the  touch,  and  there  are  the 
usual  concomitants  of  fever,  rapid  pulse,  dry  skin,  thirst,  head- 
ache, mental  excitement  and  general  malaise.  The  symptoms 
abate  somewhat  during  the  day,  becoming  worse  at  night. 
After  the  third  or  fourth  day  the  symptoms  become  gradually 
milder  and  the  arthritic  inflammation  disappears  in  about  ten 
days. 

The  urine  during  an  attack  is  scanty  and  strongly  acid, 
depositing  urates  upon  standing.  The  amount  of  uric  acid 
eliminated  during  the  attack  varies ;  occasionally  none  is  found, 
at  other  times  it  may  be  present  in  excess.  After  the  attack, 
the  quantity  of  urine  is  increased  and  its  specific  gravity  is 
diminished  but  it  remains  hyperacid  and  there  is  a  large  excess 
of  uric  acid  for  several  days. 

The  acute  attack  of  regular  gout  is  often  followed  by  an 
acute  attack  of  irregular  or  retrocedent  gout. 

After  several  attacks,  tophi  form  in  the  joints  and  in  other 
places,  the  attacks  becoming  less  frequent  and  in  the  aged  less 
severe. 


356  PATHOLOGICAL   OLD   AGE 

The  protean  character  of  irregular  gout  makes  a  general 
description  of  this  condition  impossible.  Disorders  of  the 
circulatory,  respiratory,  nervous,  digestive  and  urinary  systems, 
of  the  skin,  bones,  joints,  and  organs  of  special  sense,  have  all 
been  attributed  to  goutiness,  and  often  improperly.  The  only 
variety  about  which  there  can  be  no  question  is  retrocedent  gout. 
Immediately  following  an  acute  attack  of  regular  gout,  there 
sometimes  occur  acute  symptoms  of  gastric,  intestinal,  cardiac 
or  nervous  disorders.  They  come  on  suddenly  and  may  subside 
as  suddenly  without  treatment.  The  gastric  symptoms  are 
those  of  cardialgia  or  of  acute  gastritis;  the  intestinal  symptoms 
resemble  colic  with  constipation  or  diarrhea.  The  cardiac  symp- 
toms are  those  of  a  mild  angina.  The  nervous  symptoms 
simulate  apoplexy  or  aphasia,  or  there  may  be  mental  aberration. 

There  is  no  one  pathognomonic  symptom  of  goutiness  and 
the  diagnosis  must  often  be  made  by  the  family  history  in  the 
absence  of  other  etiological  factors.  The  diagnosis  of  the 
pathological  lesion  itself  may  not  be  difficult,  but  it  is  often 
important  to  determine  the  etiological  factor  before  instituting 
treatment.  The  affections  most  frequently  associated  with  the 
gouty  diathesis  are  catarrhs,  neuralgias,  muscle  cramps,  and  a 
form  of  nephritis  called  gouty  kidney,  which  presents  as  its 
principal  symptom  occasional  uric  acid  "showers,"  and  deposits 
of  gravel  in  the  urine.  Burning  and  itching  of  the  feet  may  be 
due  to  the  gouty  diathesis  and  the  chronic  eczema  of  the  aged  is 
frequently  associated  with  goutiness.  Glaucoma,  iritis,  keratitis, 
etc. ,  have  been  attributed  to  it.  Other  diseases,  like  emphysema, 
asthma,  aneurysms,  cardiac  inefficiency,  thrombosis,  hemor- 
rhoids and  hepatic  congestion,  have  been  ascribed  to  it.  Simi- 
larly there  have  been  described  gouty  pharyngitis,  gouty  cir- 
rhosis, arthritic  colics,  gouty  phlebitis,  gouty  myalgia,  gouty 
kidney,  etc.  Of  these  the  gouty  kidney  alone  gives  clear 
symptoms,  pointing  to  the  underlying  condition.  These  are 
an  intermittent  albuminuria  which  may  be  cyclic,  and  occasional 
showers  of  uric  acid,  an  excess  of  phosphates  or  crystals  of  cal- 
cium oxalate. 

In  many  cases  of  visceral  disease  the  only  point  in  favor  of 
a  diagnosis  of  goutiness  is  a  family  history  of  gout  with  absence 
of  any  other  etiological  factors.  If  the  disease  comes  on  sud- 
denly, and  especially  if  the  urine  shows  an  excess  of  uric  acid, 


gout  357 

the  diagnosis  is  strengthened.  But  even  where  we  are  certain 
that  the  gouty  diathesis  exists  we  must  consider  all  other 
etiological  factors  that  may  produce  the  condition  present  and 
eliminate  them  before  we  can  make  a  positive  diagnosis  of  irregu- 
lar gout. 

Treatment. — In  most  cases  of  regular  gout  the  physician  is 
first  called  during  an  acute  attack  and  then  simply  for  the  relief 
of  pain.  Colchicum  and  its  preparations  have  stood  the  test 
of  time  and  these  are  our  only  trustworthy  remedies.  But 
the  indiscriminate  use  of  this  drug  in  every  case  of  gout  and  at 
every  stage  betrays  an  inexcusable  ignorance  of  its  action. 
Colchicum  is  only  of  service  during  an  acute  attack  and  such 
attacks  are  infrequent  in  the  aged.  It  is,  moreover,  a  powerful 
cardiac  depressant  and  gastric  irritant  and  is  cumulative  in 
its  effects.  The  dose  is  1 5  minims  of  the  tincture  or  wine  every 
four  hours  until  the  pain  is  relieved  when  its  use  should  be 
stopped.  Though  usually  prescribed  in  combination  with 
potassium  iodide  the  latter  drug  has  no  effect  upon  the  attack, 
neither  shortening  nor  ameliorating  it. 

If  an  acute  attack  does  occur  in  the  aged  it  is  safer  to  give 
1/2-milligram  dose  of  colchicine,  repeated  if  necessary  in  four 
hours,  but  no  more  for  another  twenty-four  hours.  The  urine 
should  be  made  alkaline  by  the  persistent  use  of  potassium  bicar- 
bonate and  a  daily  evacuation  of  the  bowels  should  be  secured. 
For  local  treatment  the  application  of  hot  water  followed  by  a 
cocaine  ointment  or  liniment  will  afford  temporary  relief.  The 
pain  may  be  of  such  severity  that  it  becomes  necessary  to 
resort  to  narcotics.  In  that  case  we  can  give  morphine  combined 
with  or  following  a  minute  dose  of  atropia.  The  salicylates 
and  iodoform  in  grain  doses  have  been  given  with  apparent 
benefit  in  some  cases.  The  treatment  in  the  intervals,  i.e., 
between  the  acute  attacks,  is  mainly  hygienic  and  dietetic. 
Remarkable  results  have  been  obtained  at  some  of  the  European 
spring  resorts  but  (as  stated  in  connection  with  diabetes) 
it  is  probable  that  the  benefit  derived  is  due  more  to  the  strict 
regimen  than  to  the  effect  of  the  waters,  for  the  same  waters 
taken  at  home  do  not  produce  the  same  effect,  while  cases  of 
gout  occur  even  among  inhabitants  of  these  resorts  who  do  not 
follow  hygienic  and  dietetic  rules.  The  principal  resorts  for 
gouty   patients   are    Carlsbad,    Franzensbad,    Marienbad   and 


358  PATHOLOGICAL   OLD   AGE 

Teplitz,  all  in  Bohemia.  The  hygienic  measures  are  a  dry- 
climate,  frequent  warm  bathing,  warm  clothing  to  guard  against 
sudden  changes  of  temperature,  mild  active  exercise  and  a 
strict  regulation  of  diet.  Lime  salts  and  sodium  salts,  especially 
common  table  salt,  should  be  avoided  as  far  as  possible.  Malt 
liquors,  wines,  cider  and  all  fermentation  products  are  to  be 
prohibited.  If  alcoholic  drinks  are  required  we  can  allow 
whiskey  but  no  gin.  Light  meats  may  be  taken  but  dark  meats, 
liver,  kidneys,  sweetbreads  and  other  glandular  meats  are 
injurious.  A  vegetable  diet  is  best,  but  fried  dishes,  pastries, 
pies,  sweets  or  candies,  and  an  excessive  amount  of  farinaceous 
food,  tomatoes,  rhubarb,  and  sweet  potatoes  do  harm. 

There  is  no  specific  treatment  for  irregular  gout.  The 
pathological  conditions  in  the  viscera  must  be  treated  and  the 
hygienic  and  dietetic  measures  given  must  be  adhered  to. 
Among  drugs,  there  is  none  giving  uniform  results.  Piperazine 
hastens  the  elimination  of  uric  acid,  and,  in  some  cases,  a  pro- 
longed course  of  piperazine  water  seems  to  ward  off  acute  attacks; 
in  other  cases  it  is  worthless.  The  same  applies  to  the  alkaline 
treatment  with  citrate  of  potash  or  lithia.  The  iodides  have  no 
effect  in  this  disease.  Phosphoric  acid  has  apparently  given 
good  results  in  some  cases,  but  in  others  it  seemed  to  have  had 
an  opposite  effect.  Diet  and  hygiene  are  our  only  reliable 
measures. 

DIABETES  MELLITUS 

Diabetes  mellitus  is  a  clinical  syndrome,  the  most  important 
symptom  of  which  is  a  glycosuria,  which  arises  from  a  defect  in 
the  assimilation  of  carbohydrates,  sugar  then  being  found  in 
the  blood  and  tissues  which  is  eliminated  by  the  urine  in  quan- 
tities far  exceeding  the  normal  amount. 

Glycosuria  itself  is  not  pathognomonic  of  diabetes  for  it  may 
be  produced  experimentally  by  the  ingestion  of  large  quantities 
of  sugar.  In  this  case  there  is  no  perversion  of  metabolism, 
but  simply  an  inability  of  the  normal  metabolic  processes  to 
completely  convert  an  excessive  quantity  of  sugar  at  one  time. 
After  the  excess  has  been  eliminated  the  urine  becomes  normal. 
If  the  milk  glands  are  removed  shortly  before  or  after  parturition 
there  is  a  temporary  glycosuria,  the  process  by  which  glycogen 


Paget's  Disease  Radiogram  of  lower  jaw  showing  waste  of  bony  structure. 

of  S.  Epstein,  New  York.) 


(Courtesy 


DIABETES  MELLITUS  359 

is  converted  into  galactose  and  milk  sugar  being  halted,  and 
grape  sugar,  an  intermediate  product,  is  then  formed.  This 
grape  sugar  is  eliminated  by  the  urine.  Glycosuria  may  also 
occur  during  or  after  diseases  of  the  liver,  brain,  the  ductless 
glands,  infectious  fevers,  pregnancy  and  after  ingestion  of  poi- 
sons. In  some  of  these  cases  the  glycosuria  may  persist  long 
after  the  cause  has  passed  away.  Some  authorities  declare 
that  this  form  of  glycosuria  being  due  to  a  perversion  of  carbo- 
hydrate metabolism  should  also  be  called  diabetes  mellitus, 
others  will  not  apply  the  term  diabetes  to  this  temporary 
glycosuria,  as  it  disappears  normally,  but  apply  this  term  to  a 
more  or  less  permanent  glycosuria  which  in  its  milder  form  can 
be  controlled  by  diminishing  the  intake  of  carbohydrates. 
Still  others  insist  that  there  is  not  diabetes  mellitus  unless  the 
attending  symptoms  of  polyuria,  polydipsia,  bulimia  and  ema- 
ciation are  present.  Since  neither  the  nature  nor  the  patho- 
genesis of  diabetes  is  known,  the  term  will  here  be  applied  to 
any  glycosuria  that  is  due  to  perversion  of  the  metabolism  of 
carbohydrates,  whether  primary  or  secondary,  temporary  or 
permanent.  It  should  not  be  applied  to  simple  transitory 
glycosuria  arising  from  an  excessive  ingestion  of  sugar,  nor  to 
the  glycosuria  following  amputation  of  the  breast. 

Some  authors  claim  that  there  are  many  forms  of  diabetes 
mellitus  depending  upon  the  gravity,  stage,  probable  etiological 
factor,  complications,  etc.  Diabetes,  however,  really  appears 
in  but  two  forms,  the  temporary,  self-limited  form  which  is 
secondary  to  the  diseases  just  mentioned,  and  the  more  or  less 
permanent  one,  which  is  really  the  true  diabetes  mellitus. 

True  diabetes  mellitus  may  present  its  accompanying  symp- 
toms in  a  marked  degree  or  may  appear  with  symptoms  so  mild 
as  to  be  unnoticed.  In  some  cases  a  progressive  loss  in  weight 
first  attracts  the  attention  of  the  patient,  in  other  cases  there 
may  be  a  vague  feeling  of  malaise  without  any  clearly  denned 
symptoms  and  an  examination  of  the  urine  is  necessary  to  clear 
up  the  diagnosis. 

Notwithstanding  an  enormous  amount  of  research  work 
in  metabolism,  the  processes  by  which  carbohydrates  are  con- 
verted into  glycogen  and  from  glycogen  into  the  various  sugars 
and  fats,  is  still  undetermined. 

It  is  believed  that  glycolitic  agents,  in  the  nature  of  ferments, 


360  PATHOLOGICAL   OLD   AGE 

exist  in  the  pancreas,  kidneys,  lungs,  white  blood  corpuscles, 
etc.,  and  that  these  ferments  cause  the  transformation  of  glyco- 
gen into  sugar.     A  deficiency  or  a  perversion  of  the  functions  of 
these  ferments  interferes  with  the  complete  combustion  of  the 
sugar  and  it  is  retained  in  the  blood  to  be  eliminated  by  the  urine. 
An  injection  into  a  dog  of  diabetic  urine,  from  which  the  sugar 
had  been  removed,  will  produce  glycosuria,  and  the  same  result 
follows  if  the  intestinal  contents  of  a  diabetic  person  are  injected 
into  the  intestine  of  a  dog.     A  glycosuria  is  also  produced  in 
animals  by  the  injection  of  adrenal  extract.     In  these  cases 
lesions  of  the  pancreas  are  found,  evidently  due  to  the  action 
of  the  adrenalin  upon  the  pancreatic  cells  of  the  islands  of 
Langerhans.     The   adrenals   do   not   themselves   affect   carbo- 
hydrate metabolism.     It  is  their  overstimulation  that  causes 
the  production  of  excessive  secretion  which  interferes  with  the 
nutrition  of  the  pancreatic  cells,  the  function  of  these  cells  being, 
probably,   the  secretion  of  the  glycolitic  ferment.     In  about 
50  per  cent,  of  diabetic  cases  these  cells  are  found  in  a  state  of 
hyaline  or  granular  degeneration,  or  in  a  state  similar  to  that 
found  in  other  organs  undergoing  senile  involution,  i.e.,  atrophy 
and  sclerosis.     The  blood  in  the  aged  has  the  tendency  to  hold 
the  products  of  incomplete  and  perverted  metabolism,  also  the 
products  of  intestinal  decomposition  and  other  toxic  matter; 
likewise  an  excess  of  lime  salts  and  waste  material,  and  these 
abnormal  substances  do  not  produce  the  same  constitutional 
disturbances   that   appear   in   younger   individuals.     For   this 
reason  diseases  due  to  disturbed  metabolism  like  gout,  diabetes, 
chronic  rheumatism,  and  some  infectious  diseases  like  erysipelas 
and  diphtheria  appear  in  a  mild  and  exceedingly  chronic  form. 
As    diabetes   in   the   aged   is   almost    always    associated  with 
arteriosclerosis,  there  may  be  an  etiological  factor  common  to 
both,  or   the   arteriosclerosis   may  produce  malnutrition  with 
consequent   degeneration  of  the  cells  furnishing  the  glycolitic 
ferment. 

Many  theories  have  been  advanced  to  explain  the  production 
and  conversion  of  sugar,  and  the  causes  for  the  impairment 
of  the  chemical  processes  involved.  Since  many  of  the  theories 
apply  to  some  cases  or  hold  good  under  some  circumstances 
and  fail  in  others,  it  is  evident  that  there  are  several  causes 
and  various  processes  that  can  produce  the  same  end  result. 


DIABETES  MELLITUS  361 

It  would  serve  to  no  purpose  to  enumerate  these  theories  or 
dilate  upon  the  elaborate  chemical  formulae  used  to  explain 
carbohydrate  metabolism.  Magnus  Levy  has  pointed  out 
sources  of  error  in  theories  based  upon  animal  experimentation. 
In  these  experiments  a  rapid,  radical  and  serious  damage  is 
done  to  the  organism.  In  human  diabetes  the  decrease  of 
sugar  utilization  goes  on  slowly  and  progressively  and  the 
organism  partly  adapts  itself  to  the  new  conditions.  Moreover, 
the  dog  (most  frequently  used  in  these  experiments)  is  a  car- 
nivorous animal,  and  there  is  some  difference  in  the  metabolism 
of  carbohydrates.  This  may  account  for  the  rarity  of  acidosis 
in  canine  diabetes. 

While  in  about  one-half  of  all  cases  lesions  of  the  pancreas 
are  present  and  in  most  other  cases  lesions  of  the  liver  or  of  the 
nervous  system  are  found,  there  are  some  cases  presenting  no 
lesion  whatever  and  apparently  there  is  no  etiological  factor  to 
account  for  the  disease,  while  in  other  cases  lesions  are  found 
but  it  is  impossible  to  determine  any  relation  between  them  and 
the  disease.  Extirpation  of  the  pancreas  is  followed  by  diabetes, 
but  the  disease  may  be  present  with  a  healthy  pancreas.  Extir- 
pation of  the  thyroid  in  the  dog  was  followed,  in  over  60  per  cent, 
of  experiments,  by  diabetes  yet  diabetes  is  found  complicated 
by  or  associated  with  Basedow's  disease. 

This  much  is  certain:  there  are  numerous  factors  which 
can  disturb  carbohydrate  metabolism,  and  this  disturbance 
may  occur  anywhere  between  the  intestines,  i.e.,  the  point  of 
ingress  into  the  circulation,  and  the  kidneys,  the  point  of  egress. 
It  may  result  from  some  lesion  in  one  of  the  organs  producing 
the  glycolitic  agent,  or  it  may  occur  without  such  lesion,  as  a 
result  of  functional  disturbance  in  cells  engaged  in  the  process 
of  metabolism.  The  sugar  is  derived  from  the  carbohydrates 
taken  into  the  system,  but  it  may  also  be  derived  from  the 
proteins,  Kulz  having  found  that  in  a  diabetic  kept  on  an  exclu- 
sive protein  diet,  increase  in  this  diet  increased  the  sugar  output, 
while  Pfluger  found  that  the  sugar  may  come  from  the  proteins 
of  the  body.  It  is  possible  that  some  sugar  is  derived  from  the 
glycerine  of  fat. 

Etiology. — Statistics  show  a  constantly  increasing  proportion 
of  diabetics  in  civilized  countries.  This  may  be  ascribed  to 
increased  mental  and  nervous  strain  with  decreasing  physical 


362  PATHOLOGICAL   OLD    AGE 

exercise  and  to  changes  in  the  mode  of  life  brought  about  by 
the  introduction  of  new  methods  of  preparing  food,  and  of  food 
that  is  too  rich. 

Heredity  seems  to  have  some  influence  as  an  etiological 
factor,  but  it  is  a  question  whether  such  influence  is  really 
inherent  or  is  simply  the  result  of  similar  environment  and  mode 
of  life.  The  relative  frequency  of  diabetes  among  Jews  is  prob- 
ably due  to  the  fact  that  they  are  mostly  engaged  in  sedentary  or 
non-active  occupations  and  their  mode  of  life  favors  mental 
and  nervous  strain.  The  disease  occurs  occasionally  in  families 
having  a  gouty  diathesis  or  a  disposition  to  obesity,  but  while 
some  see  therein  an  argument  in  favor  of  heredity,  it  is  probably 
simply  coincidence.  Diet  is  an  uncertain  etiological  factor, 
some  authorities  claiming  that  a  vegetarian  diet  predisposes 
to  diabetes,  others  showing  the  comparative  rarity  of  diabetes 
among  peasants  who  live  almost  exclusively  on  a  vegetable  diet. 
Diabetes  does  not  occur  more  frequently  among  sugar  and  candy 
workers  than  among  others  and  while  the  consumption  of  sugar 
is  far  greater  among  females,  diabetes  occurs  in  only  one-third 
as  many  females  as  males.  It  is  found  frequently,  however, 
among  obese  beer  drinkers.  In  cases  where  the  disease  is 
traceable  to  faulty  alimentation,  either  in  carbohydrate  excess 
or  disproportion,  there  is  probably  a  dyscrasia  or  predisposition 
to  this  disease. 

It  is  often  impossible  to  determine  what  the  exciting  cause  is. 
The  disease  sometimes  follows  a  shock  or  fright,  more  often  there 
has  been  a  long  period  of  worry  or  mental  strain.  It  occasion- 
ally follows  cerebral  traumatism.  Many  cases  follow  acute 
general  infectious  diseases,  and  it  has  been  found  after  local 
infections.  In  by  far  the  largest  number  of  cases,  however, 
there  is  a  disease  of  the  pancreas  or  liver.  In  other  cases  there  is 
a  nervous  or  mental  defect,  a  neurosis  or  psychosis  preceding  or 
accompanying  the  diabetes.  Since  we  do  not  know  the  patho- 
genesis of'  the  disease,  we  frequently  assume  a  causal  relation 
without  any  other  basis  than  absence  of  other  etiological  factors. 
The  temporary  glycosuria  of  secondary  diabetes  may  produce  a 
permanent  diabetes. 

Pathology. — In  some  cases  no  pathological  lesion  or  condition 
can  be  found,  except  an  excess  of  sugar  in  the  blood,  the  proportion 
being  as  high  as  1  to  250  instead  of  1  to  1000  or  less.     Fat  granules 


DIABETES  MELLITUS  363 

may  appear  in  the  blood  plasma.  The  most  frequent  patholog- 
ical condition  is  a  degeneration  of  the  cells  of  the  islands  of 
Langerhans  in  the  pancreas.  There  is  occasionally  a  pancreatitis 
or  a  degeneration  in  some  other  part  of  the  organ.  The  liver  is 
often  hypertrophied,  but  in  senile  cases  it  is  generally  atrophied 
and  sclerotic.  In  the  rare  bronzed  diabetes  in  which  the  viscera 
and  skin  are  pigmented  there  is  a  pigmentary  hypertrophic 
cirrhosis  of  the  liver,  the  pigmentation  of  the  other  organs  being 
probably  secondary  to  the  change  in  the  liver.  In  the  kidneys 
there  is  frequent  evidence  of  nephritis.  Various  other  kidney 
lesions  have  been  noted,  but  these  may  have  been  incidental 
complications.  The  same  can  be  said  of  other  lesions  occasion- 
ally found  in  diabetic  cases,  as  some  are  undoubtedly  secondary 
to  arteriosclerosis. 

Symptoms. — The  disease  is  usually  well  advanced  before 
any  symptoms  pointing  to  it  make  their  appearance.  In  one 
case  the  patient  did  not  notice  any  loss  in  weight  or  strength,  or 
excessive  thirst  until  two  years  after  a  glycosuria  was  accident- 
ally discovered.  In  the  temporary  diabetes  following  an  infectious 
or  other  disease  the  patient  makes  a  slow  recovery  and  does  not 
regain  strength  and  weight  as  fast  as  he  should  in  normal  con- 
valescence. The  appetite  improves,  but  there  is  no  correspond- 
ing gain  in  weight,  and  there  is  a  polydipsia,  though  it  is  not  as 
marked  as  in  the  permanent  form  of  diabetes.  The  urine  is 
slightly,  if  at  all,  increased  in  amount,  but  it  contains  from  1/2 
to  2  per  cent,  of  sugar.  A  diminution  in  the  intake  of  carbo- 
hydrates will  diminish  the  quantity  of  sugar;  however,  it  is 
rarely  necessary  to  resort  to  an  exclusive  protein  diet  to  get  a 
sugar-free  urine.  By  simply  limiting  the  ingestion  of  carbo- 
hydrates in  these  cases  the  glycosuria  will  disappear. 

In  the  permanent  diabetes  the  earliest  symptom  is  usually  a 
loss  in  strength,  often  ascribed  to  ageing.  The  patient  notices 
that,  in  spite  of  a  good  appetite,  he  loses  in  weight,  and  it  is  for 
this  loss  in  weight  that  he  seeks  medical  advice.  Close  question- 
ing may  then  bring  out  the  additional  symptoms  thirst  and  poly- 
uria. Ageing  patients  do  not  pay  attention  to  these  symptoms 
until  they  become  severe,  but  will  readily  notice  loss  in  weight 
and  strength  and,  ascribing  these  to  age,  they  become  depressed. 
When  the  disease  is  well  advanced  the  mouth  becomes  dry  and 
the  tongue  red,   glazed  and  furrowed.     The  urine  is  greatly 


364  PATHOLOGICAL    OLD    AGE 

increased  in  quantity  necessitating  frequent  micturition.  The 
appetite  increases  until  there  is  a  constant  desire  for  food  even 
after  the  patient  had  just  finished  a  hearty  meal.  This  bulimia 
is  greatly  aggravated  as  soon  as  the  carbohydrates  are  reduced 
in  the  course  of  treatment,  and  where  wheat  in  the  form  of  bread 
is  withdrawn,  the  appetite  may  be  insatiable.  The  thirst  keeps 
pace  with  the  polyuria,  which  in  turn  increases  as  the  amount  of 
sugar  increases.  When  associated  with  arteriosclerosis  the 
symptoms  of  the  latter  disease  appear  in  high  blood  pressure, 
headache  and  vertigo,  mental  and  emotional  depression.  The 
temperature  is  often  subnormal.  Constipation  is  a  frequent 
complication  and  is  often  associated  with  gastric  disturbances. 
Nervous  symptoms  appear,  especially  when  the  disease  is  of 
nervous  origin.  There  may  be  neuralgia,  muscle  pain,  paralysis, 
etc.  The  skin  becomes  dry  and  a  slight  trauma,  such  as  a  scratch 
or  the  prick  of  a  pin,  will  often  become  an  extensive  and  serious 
lesion.  These  surface  lesions  rarely  heal  without  suppuration, 
and  if  deep-seated,  they  may  become  gangrenous.  It  is  prob- 
able that  the  frequency  of  furuncles,  carbuncles,  chronic  ulcers 
and  gangrene  in  diabetic  cases  is  due  to  the  increased  amount 
of  sugar  in  the  blood,  the  blood  thereby  becoming  a  good  cul- 
ture medium  for  the  pyogenic  cocci.  Eczema  of  the  genitals 
and  herpes  zoster  are  occasional  complications.  The  most  im- 
portant symptom,  however,  is  glycosuria.  The  quantity  of 
urine  is  generally  dependent  upon  the  amount  of  sugar,  al- 
though in  diabetes  following  cranial  traumatism  we  may  find  a 
polyuria  (5  to  6  liters  in  twenty-four  hours)  with  a  sugar  con- 
tent of  but  1  1/2  to  2  per  cent.  Usually,  if  there  is  over  5  per 
cent,  of  sugar,  there  will  be  from  4  to  5  liters  of  urine  in  twenty- 
four  hours,  and  as  the  sugar  percentage  sinks  the  total  quan- 
tity of  urine  diminishes.  Cases  passing  as  much  as  28  liters 
in  one  day  have  been  reported.  The  excretion  is  generally 
more  voluminous  at  night  than  by  day  and  there  is  often  a 
retention  of  a  few  drops  which  pass  away  a  few  moments  after 
the  bladder  had  been  apparently  emptied.  If  dropped  on  the 
clothes  and  dried,  there  will  be  a  deposit  of  sugar.  Naunyn 
gives  the  following  figures  which  show  the  relation  between 
the  amount,  specific  gravity  and  sugar  percentage. 
2  liters  passed  in  24  hours  should  have  a  specific  gravity  of  1028 
to  1030  corresponding  to  2  to  3  per  cent,  sugar. 


DIABETES  MELLITUS  365 

3  liters  passed  in  24  hours  should  have  a  specific  gravity  of  1028 
to  1032  corresponding  to  3  to  5  per  cent,  sugar. 

5  liters  passed  in  24  hours  should  have  a  specific  gravity  of  1030 

to  1035  corresponding  to  5  to  7  per  cent,  sugar. 

6  to  10  liters  passed  in  24  hours  should  have  a  specific  gravity  of 

1030  to  1042  corresponding  to  6  to  10  per  cent,  sugar. 

The  amount  of  urea  is  generally  increased  and  this  is  probably 
due  to  the  increased  ingestion  of  proteins  and  if  much  meat  has 
been  taken  there  may  be  also  a  considerable  amount  of  uric  acid. 

Albumin  is  frequently  found  in  the  urine  of  diabetics.  In 
some  cases  it  is  a  symptom  of  a  complication,  as  nephritis,  in 
other  cases  it  is  due  to  the  excessive  protein  food  introduced  in 
the  course  of  treatment,  in  still  other  cases  it  is  apparently  due 
to  a  faulty  metabolism  of  proteids,  which  accompanies  the  meta- 
bolic defect  in  diabetes.  Many  theories  have  been  advanced  to 
explain  the  presence  of  this  albumin,  but  none  are  satisfactory. 
Still  more  unsatisfactory  are  the  theories  advanced  for  the  pres- 
ence of  amino-acids  and  acetone  bodies  found  in  the  urine  of 
late  cases  of  diabetes.  Acidosis  occurs  only  in  grave  cases,  and 
rarely  in  the  aged.     Phosphaturia  is  a  frequent  complication. 

Normal  blood  contains  about  1/4  part  of  sugar  in  1000, 
which  may  be  increased  to  1  part  or  1  1/4  part  immediately 
after  the  ingestion  of  a  considerable  amount  of  saccharine  matter, 
but  several  hours  later  the  sugar  proportion  has  dropped  to 
normal.  In  diabetes  the  sugar  in  the  blood  may  be  increased 
to  3  or  4  parts  in  1000,  but  the  proportion  varies  according  to  the 
ingestion  of  carbohydrates  and  gravity  of  the  disease.  The 
amount  of  fat  in  the  blood  is  generally  increased  and  may  reach 
the  proportion  of  270  parts  in  1000  (Frugoni).  In  the  early  part 
of  the  disease  the  blood  is  hydremic,  but  after  polyuria  becomes 
pronounced  it  is  concentrated,  with  a  specific  gravity  of  1030  to 
1059.  The  blood  is  sometimes  lighter  in  color,  probably  due  to 
the  fat,  as  the  hemoglobin  content  is  usually  normal. 

Sugar  is  sometimes  found  in  the  sweat,  occasionally  in  ascites 
and  other  serous  transudations,  but  rarely  in  the  saliva.  Dia- 
betic coma,  which  usually  occurs  in  younger  individuals  at  the 
closing  stage  of  the  disease,  is  infrequent  in  old  age.  This  coma 
is  probably  due  to  the  toxic  effects  of  the  acetone  bodies.  It 
may  come  on  slowly  or  rapidly  and  death  may  follow  in  a  few 
hours  or  it  may  be  delayed  for  several  days.     The  diagnosis 


366  PATHOLOGICAL   OLD    AGE 

of  diabetes  mellitus  is  simple,  but  error  may  occur  if  the  patient 
is  first  seen  during  the  comatose  state.  If  the  diagnosis  cannot 
be  determined  from  the  history,  it  may  be  necessary  to  withdraw 
the  urine  by  means  of  a  soft  catheter.  If  there  is  no  sugar  it  is 
not  diabetes.  Diabetes  in  the  aged  is  generally  mild  but  ex- 
tremely persistent.  Under  a  restricted  carbohydrate  diet 
patients  may  live  for  years  without  discomfort.  Carelessness 
in  diet  or  a  sudden  shock  may  increase  the  sugar  output  and  re- 
sult in  acidosis. 

Treatment. — Since  we  do  not  know  what  prevents  the  com- 
plete combustion  of  sugar  in  diabetes,  the  only  rational  method 
of  treatment  is  to  limit  the  ingestion  of  carbohydrates.  The  die- 
tetic treatment  is  still  our  main  reliance  in  the  control  of  this 
disease,  supplemented  by  measures  which  have  given  favorable 
results  in  some  cases.  The  only  unalterable  rule  is  to  diminish 
the  amount  of  the  carbohydrates,  but  while  in  some  cases  it  will 
be  necessary  to  increase  the  caloric  value  of  the  food,  in  other 
cases,  the  patient  will  do  better  if  the  caloric  value  is  not  increased, 
but  in  the  obese,  or  where  the  disease  is  far  advanced,  it  must 
be  diminished.  The  aged  diabetic  requires  a  diet  containing 
about  the  same  caloric  value  as  in  health,  which  is  about  30 
calories  per  kilogram  weight  daily,  or  about  2000  calories  at  a 
weight  of  145  pounds. 

It  is  rarely  necessary,  nor  is  it  advisable,  to  make  a  sudden 
and  profound  change  in  the  diet  by  excluding  carbohydrates 
entirely,  as  in  all  early  cases,  and  in  many  advanced  cases  too,  the 
organism  can  tolerate  a  certain  amount  of  carbohydrate  food 
without  the  production  of  sugar.  It  is,  therefore,  necessary  to 
determine  the  point  of  carbohydrate  tolerance  and  this  can  be 
done  by  placing  the  patient  upon  Von  Noorden's  Standard  Test 
Diet  which  is  as  follows: 


Von  Noorden's  Standard  Test  Diet 

Breakfast. — 200  grams  coffee  or  tea  with  one  or  two  table- 
spoonfuls   of   thick   cream. 

100  grams  of  hot  or  cold  meat  (weighed  after  cooking). 
Two  eggs,  with  or  without  bacon  or  corned  beef. 
50  grams  of  white  bread. 


DIABETES  MELLITUS  367 

Lunch. — Two  eggs  cooked  as  desired,   but  without  flour; 
or  any  other  hors  d'oeuvre  free  from  flour. 

Meat  (boiled  or  roasted),  fish,  venison  or  fowl,  accord- 
ing to  taste,  about  200  to  250  grams  altogether  (weighed 
when  cooked). 

Vegetables,  such  as  spinach,  cabbage,  cauliflower  or 
asparagus,  prepared  with  broth,  butter  or  other  fat,  eggs 
or  thick  sour  cream,  but  without  any  flour. 

20  to  25  grams  creamy  cheese  (such  as  Brie,  Camem- 
bert,  etc.) ;  plenty  of  butter. 

Two  glasses  of  light  white  or  red  wine,  if  desired. 
One  small  cup  of  coffee  with  one  or  two  tablespoonfuls 
of  thick  cream. 

50  grams  of  white  bread. 
Dinner. — Clear  meat  soup,  with  egg  or  green  vegetable  in  it. 
One  or  two  meat  dishes  as  at  lunch. 
Salad  of  lettuce,  cucumber  or  tomatoes. 
Wine. 
No  bread. 

Drinks  during  the  day,  exclusive  of  wine,  one  or  two 
bottles  of  aerated  water. 
The  total  urine  excreted  during  the  twenty-four  hours  is 
collected,  that  of  the  day  and  of  the  night  separately,  and  is 
examined  quantitatively  for  sugar.  Both  the  percentage  con- 
tents, and  more  especially  the  whole  quantity  of  sugar  excreted 
in  the  twenty -four  hours  is  noted. 

If  on  this  fare  no  sugar  is  excreted,  the  quantity  of  bread  is 
gradually  increased  until  sugar  does  appear  in  the  urine.  If  on 
the  other  hand,  sugar  is  excreted  with  this  test  diet,  the  patient 
is  first  kept  on  the  same  fare  until  the  daily  excretion  of  sugar  has 
become  nearly  constant.  Then  the  quantity  of  bread  is  grad- 
ually diminished.  At  each  stage  in  the  diminishing  process  the 
patient  is  kept  on  the  same  amount  of  bread  long  enough  to 
allow  the  sugar  excretion  to  get  a  constant  value,  proper  to  this 
stage. 

The  largest  amount  of  white  bread  which  can  be  taken  with- 
out causing  sugar  to  appear  in  the  urine  is  then  taken  as  that 
particular  patient's  point  of  carbohydrate  tolerance. 

These  meals  allow  100  grams  of  white  bread  having  a  60 
per  cent,  starch  content  daily.     When  the  point  of  carbohy- 


368  PATHOLOGICAL    OLD   AGE 

drate  tolerance  has  been  determined  the  amount  of  white 
bread  can  be  replaced  by  other  carbohydrates  according  to  the 
following  table  of  carbohydrate  equivalents: 

TABLE  OF  EQUIVALENTS 

30  grams  of  white  bread  equal  in  carbohydrate  contents 
Breads  and  Other  Farinaceous  Foods 

Brown  bread 40  grams 

Corn  bread 40  grams 

Rye  bread 36  grams 

Graham  bread 36  grams 

Gluten  bread 36  grams 

Biscuit 32  grams 

Roll  (French) 32  grams 

Roll  (Vienna) 32  grams 

Crackers  (Boston) 24  grams 

Crackers  (Graham) 24  grams 

Crackers  (Oyster) 24  grams 

Pretzel 24  grams 

Ginger  bread 28  grams 

Chocolate  cake 28  grams 

Sponge  cake 28  grams 

Cookies  (molasses) 24  grams 

Lady  fingers 24  grams 

Doughnuts 32  grams 

Spaghetti ' 120  grams 

Macaroni 120  grams 

Vermicelli 120  grams 

Almond  meal 260  grams 

Soja  bean  meal 200  grams 

Potato  gluten  biscuit 180  grams 

Pure  gluten  biscuit 200  grams 

Barkers  gluten  food,  A 409  grams 

Barkers  gluten  food,  B 296  grams 

Barkers  gluten  food,  C 216  grams 

Vegetable  gluten 68  grams 

Gum  gluten 48  grams 

Glutona 32  grams 

Glutosac  bread 60  grams 

Protopuff  No.  1 jgo  grams 

Protopuff  No.  2 48  grams 

Jireh  whole  wheat  bread 48  grams 

Vegetables 

Celery ^o  grams 

Radishes 4So  grams 

Asparagus 55o  grams 

Cabbage 310  grams 

Cauliflower 400  grams 


DIABETES  MELLITUS  369 

TABLE  OF  EQUIVALENTS.— (Continued) 

Cucumber 600  grams 

Lettuce 600  grams 

Mushrooms 250  grams 

Sauerkraut 450  grams 

Spinach 600  grams 

Tomatoes 450  grams 

Beets  (cooked) 260  grams 

Lima  beans 200  grams 

Carrots 260  grams 

Corn  (canned  or  green) 88  grams 

Egg  plant 360  grams 

Parsnips 140  grams 

Green  peas 120  grams 

Potatoes 88  grams 

Sweet  potatoes 30  grams 

Turnips 224  grams 

Cereals 

Barley  (cooked) 27  grams 

Hominy  (cooked) 100  grams 

Oatmeal  (cooked) 160  grams 

Rice  (cooked) 60  grams 

Farina  (cooked) 100  grams 

Fruits 

Apples 180  grams 

Bananas 80  grams 

Grapes 128  grams 

Muskmelon 448  grams 

Oranges 160  grams 

Peaches 200  grams 

Pears 200  grams 

Prunes 96  grams 

Strawberries 260  grams 

Watermelon 900  grams 

Cherries 150  grams 

Blackberries 160  grams 

Cranberries 180  grams 

Currants 160  grams 

Raspberries 150  grams 

Grapefruit  (weighed  with  skin) 750  grams 

Desserts 

Apple  pie 40  grams 

Lemon  pie 36  grams 

Custard  pie 78  grams 

Rice  pudding 56  grams 

Tapioca  pudding 60  grams 

24 


370  PATHOLOGICAL   OLD   AGE 

TABLE  OF  EQUIVALENTS.— (Continued) 
Milk  and  Milk  Products 

Pure  milk 448  grams 

Cream 448  grams 

Koumyss 334  grams 

Matzoon 886  grams 

Kefir 750  grams 

Buttermilk 375  grams 

Condensed  milk  (sweetened) ^3  grams 

Condensed  milk  (unsweetened) 144  grams 

Evaported  cream 144  grams 

Beverages 

Beer  (dark) 250  grams 

Beer  (light) 300  grams 

Ale 298  grams 

Porter 238  grams 

Sherry  wine 510  grams 

Port  wine 258  grams 

Champagnes 108  grams 

Rhine  wines  (red) 570  grams 

Rhine  wines  (white) '. 600  grams 

Italian  wines 495  grams 

Miscellaneous 

Cocoa  (unsweetened) 50  grams 

Chocolate  (unsweetened) 60  grams 

Peanuts 80  grams 

If  for  example  the  point  of  carbohydrate  tolerance  is  found 
when  60  grams  of  white  bread  are  taken  in  a  day,  30  grams  of  the 
bread  can  be  replaced  by  120  grams  of  spaghetti  or  by  100  grams 
of  lima  beans,  112  grams  of  cream  and  112  grams  of  muskmelon. 
If  bread  is  entirely  omitted  the  craving  for  this  one  article  of  food 
becomes  intolerable  and  the  patient  will  either  starve  or  violate 
orders.  The  ordinary  gluten  bread  contains  almost  as  much 
carbohydrate  as  the  white  bread  and  most  of  the  so-called  dia- 
betic gluten  breads  contain  a  large  percentage  of  starch.  The 
only  diabetic  flour  containing  no  starch  is  casoid  flour,  which  is 
a  mixture  of  albuminoids.  If  this  is  substituted  for  the  ordinary 
white  bread  a  much  larger  quantity  of  other  carbohydrates  can 
be  taken.  Diabetics  differ  in  their  tolerance  toward  certain 
foods,  the  same  carbohydrate  equivalent  of  one  food  producing  a 
glycosuria  in  one  and  not  in  another  who  has  the  same  point  of 
tolerance.     Articles  toward  which  there  is  an  intolerance  must 


DIABETES  MELLITUS  371 

be  avoided.  Foods  that  are  absorbed  slowly,  such  as  contain  a 
large  amount  of  cellulose  for  example,  are  better  than  those  that 
are  rapidly  absorbed.  The  oatmeal  cure  recommended  by  Von 
Noorden  consists  of  the  daily  administration  of  from  200  to  250 
grams  of  oatmeal,  preferably  in  the  form  of  gruel  in  divided 
doses  at  intervals  of  two  hours.  In  addition  to  this,  from  200 
to  300  grams  of  butter  and  100  grams  of  proteid  food  are  allowed. 
Black  coffee  or  tea,  good  old  wine  or  a  little  brandy  is  permitted. 
After  three  or  four  days  of  this  diet  the  patient  is  placed  upon  a 
vegetable  diet  for  a  day  or  two,  the  vegetable  content  not  to 
exceed  the  point  of  carbohydrate  tolerance.  Various  theories 
have  been  advanced  to  explain  the  frequent  success  in  diminish- 
ing the  quantity  of  sugar  and  acetone  under  the  oatmeal  diet. 
It  has  been  suggested  that  the  large  amount  of  cellulose  in  oat- 
meals causes  very  slow  absorption,  or  that  the  large  amount  of 
water  in  gruel  diminishes  the  total  quantity  of  the  oatmeal, 
again  that  upon  a  single  carbohydrate  diet  the  appetite  wanes 
and  less  of  all  kinds  of  food  is  taken,  or  that  the  oatmeal  is  con- 
verted beyond  the  stage  of  sugar.  Some  of  these  explanations 
apply  as  well  to  other  single  carbohydrate  diets,  as  for  example  to 
the  potato  cure,  rice  cure,  etc.  It  is  certain  that  the  glycosuria 
is  diminished  whenever  the  diet  is  restricted  for  a  few  days  to  a 
single  carbohydrate  and  smaller  amounts  of  protein  and  fat  than 
normal.  If  excessive  sugar  persists  in  the  urine,  notwithstand- 
ing the  diminution  of  carbohydrates  to  the  point  of  exclusion,  the 
intake  of  protein  must  be  reduced.  These  cases,  however,  are 
rare  in  the  aged.  In  many  instances  it  is  possible  to  reduce  the 
amount  of  sugar  in  the  urine  to  1  or  1  1/2  per  cent,  without 
great  restriction  of  carbohydrates,  and  only  complete  exclusion 
of  starch  and  sugar  from  the  diet  will  bring  it  down  to  normal. 
If  the  patient  feels  well  with  a  glycosuria  containing  1  or  1  1/2 
per  cent,  of  sugar  and  does  not  lose  weight,  the  point  of  carbohy- 
drate tolerance  should  be  established  upon  that  basis.  The 
indiscriminate  use  of  fats  in  diabetes  may  lead  to  acidosis. 
Stern  has  shown  that  the  fats  containing  a  large  proportion  of 
fatty  acids  of  a  low  molecular  weight  favor  the  production  of 
acetone,  but,  if  the  fatty  acids  have  a  high  molecular  weight, 
they  yield  little  acetone.  This  would  exclude  from  the  diet 
butter  and  cream,  but  not  olive  oil,  lard  or  suet.  He  recommends 
the  yolk  of  eggs  as  the  most  valuable  fatty  substance  in  diabetes, 


3y2  PATHOLOGICAL   OLD   AGE 

especially  in  acidosis.  Instead  of  sugar,  saccharine  or  levulose 
can  be  used  to  sweeten  coffee  and  tea  and  when  these  become 
distasteful  glycerin  may  be  used  instead.  It  is  impossible  to 
arrange  a  strict  diet  list  for  the  aged  diabetic,  because  the  dis- 
ease is  rarely  severe  in  them,  therefore  much  greater  leeway  can 
be  permitted  in  the  matter  of  diet  to  maintain  physical  strength. 
An  exclusive  protein  diet  would  produce  gastric  and  intestinal 
disturbances  and  would  so  far  reduce  the  patient's  strength  that 
recovery  would  be  impossible. 

Non-dietetic  measures  include  aerotherapy,  electrotherapy, 
hydrotherapy,  hygienic  measures,  surgical  measures  and  drugs. 
Abrams  in  his  work  on  spondylotherapy  recommends  concussion 
of  the  seventh  cervical  vertebral  spine  and  reports  cases  where 
diabetes  has  been  benefited  by  this  method  of  treatment.  It 
is  well  known  that  diabetes  in  hot  countries  is  milder  and  more 
prolonged  than  in  colder  countries  and  this  has  led  to  the  dry- 
heat  treatment.  In  a  dry  air  with  a  temperature  of  from  80 
to  oo°  F.  the  glycosuria  diminishes  and  the  symptoms  of  diabetes 
become  milder.  Upon  exposure  to  cold  the  glycosuria  and 
other  symptoms  become  as  pronounced  as  before. 

The  treatment  by  electricity  has  not  been  satisfactory. 
DeKraft  reports  cures  from  the  employment  of  high-frequency 
currents,  Tousey  thinks  they  may  be  harmful,  Stern  says  they 
do  not  influence  the  intensity  of  glycosuria,  azoturia  or  aceton- 
uria.     Other  observers  make  similar  contradictory  reports. 

Many  cases  of  diabetes  are  apparently  cured  at  the  Bohemian 
mineral  springs,  especially  at  Carlsbad  and  Franzensbad.  It 
is  hardly  possible  that  the  waters  themselves  effect  the  cure, 
since  the  waters  taken  at  home  do  not  produce  the  same  results. 
This  was  shown  in  the  case  of  a  man,  age  sixty-five,  with  symp- 
toms of  diabetes  and  a  sugar  content  of  5  per  cent.,  who  after  a 
six  weeks'  course  at  Carlsbad  gave  a  sugar  content  of  but  1  1/2  per 
cent.  It  rose  soon  after  his  return,  however,  and  in  two  months 
it  again  reached  5  per  cent.,  notwithstanding  a  partly  restricted 
diet .  The  following  year  the  same  course  was  followed  by  the  same 
result.  The  third  year  he  took  the  waters  at  home,  following, 
to  a  modified  extent,  the  strict  routine  and  diabetic  regimen 
insisted  upon  at  Carlsbad,  and  his  sugar  content  dropped  to 
21/2  per  cent.  The  next  year  he  returned  to  Carlsbad  and 
there  was  again  the  usual  result,   diminished  glycosuria  and 


DIABETES  MELLITUS  373 

relief  of  other  symptoms.  Undoubtedly  the  psychic  influence 
of  the  environment  and  strict  regimen  were  the  most  important 
factors.  Free  intestinal  elimination  is  an  important  adjunct 
to  the  dietetic  measures,  and  in  some  cases  free  catharsis  with 
restricted  diet  may  effect  a  cure.  Any  of  the  saline  cathartics 
act  equally  well. 

Medicinal  measures  are  usually  required  to  relieve  symptoms 
or  to  prevent  complications,  and  sometimes  they  are  employed 
as  a  general  tonic.  Occasionally  medicinal  remedies  are  given 
to  cure  the  disease  and  there  are  reports  of  recoveries  from  the 
use  of  some  drugs.  In  every  case,  however,  the  dietetic  meas- 
ures must  be  included  in  the  treatment.  The  use  of  uranium 
nitrate  in  5 -grain  doses  will  sometimes  reduce  the  amount  of 
sugar.  Methylene  blue,  strontium  lactate,  chloride  of  gold  and 
sodium,  iodoform,  antipyrin,  mercury  bichloride,  and  arsenic 
have  all  been  recommended,  yet  they  almost  invariably  fail  to 
give  the  results  obtained  by  those  who  advocate  their  use. 
Sewall  reports  an  absence  of  sugar  after  the  administration 
of  an  infusion  of  lean  meat  acidulated  with  hydrochloric  acid 
and  Horowitz  reports  a  like  result  from  the  administration  of 
the  lactic  acid  bacilli.  Rudisch  recommends  atropine  sulphate 
in  doses  of  from  1/150  grain  gradually  increased  to  1/20  grain 
and  atropine  methylbromide  in  doses  of  2/15  grain  gradually 
increased  to  8/15  grain,  while  Stern  obtained  only  toxic  effects 
from  these  large  doses.  Codeine  has  stood  the  test  of  years 
and  is  still  frequently  used  when  dietetic  measures  alone  fail 
to  reduce  the  quantity  of  urine. 

It  is,  however,  rarely  necessary  to  resort  to  other  than 
dietary  measures  in  senile  cases  except  for  the  relief  of  distressing 
symptoms  and  as  a  prophylactic  to  prevent  coma.  When  acido- 
sis appears  sodium  bicarbonate  or  potassium  bicarbonate  must 
be  given  in  doses  of  10  grains  repeated  every  4  hours.  If  coma 
supervenes  in  spite  of  the  alkaline  treatment,  it  almost  invariably 
ends  in  death.  A  few  recoveries  are  recorded,  however,  follow- 
ing the  intravenous  injection  of  soda  bicarbonate,  using  500  c.c. 
of  a  3  per  cent,  solution,  and  giving  one  or  two  injections  daily. 
Large  quantities  of  the  salt  may  be  required  and  Hanssen  reports 
a  case  in  which  240  grams  were  given  in  10.6  liters  of  water  in 
ten  half  hourly  doses.  For  the  relief  of  thirst  the  valerianates, 
ammonium  valerianate  or  quinine  valerianate  in  5 -grain  doses, 


374 


PATHOLOGICAL   OLD   AGE 


can  be  given.  Water  acidulated  with  phosphoric  or  citric  acid 
(sweetened  with  glycerin)  and  small  pieces  of  ice  are  of  tempo- 
rary utility.  Bulimia  can  be  temporarily  controlled  by  cocaine 
hydrochlorate  given  in  i/8-grain  doses.  The  cocaine,  however, 
is  a  cardiac  depressant,  and  if  frequently  repeated,  will  cause 
habituation  and  gastric  atonicity.  Food  containing  a  large 
amount  of  cellulose,  or  requiring  much  chewing,  as  under- 
done meats,   should  be  taken  in  small  quantities  and  eaten 

slowly. 

Headache  is  usually  due  either  to  acidosis  or  arteriosclerosis 
and  the  treatment  depends  upon  the  cause. 

Jaundice  is  due  either  to  pancreatic  or  hepatic  disease.  If 
it  disappears  under  the  administration  of  calomel  given  in 
repeated  small  doses,  say  i/io  grain  every  two  hours,  or  sodium 
glycocholate  in  2 -grain  doses  twice  daily,  we  have  a  diabetes  of 
hepatic  origin  to  deal  with.  A  persistent  jaundice  under  this 
treatment  does  not  exclude  disease  of  the  liver,  but  it  points 
with  greater  force  to  pancreatic  diabetes.  Digestive  and  intes- 
tinal disorders  are  frequent  complications  of  diabetes,  due,  no 
doubt,  to  the  changed  alimentation  and  changed  character  of 
the  blood,  whereby  the  nutrition  of  the  organs  becomes  impaired. 
Occasional  lavage  will  increase  the  activity  of  the  stomach  and 
remove  food  particles  that  have  begun  to  decompose.  For 
constipation  the  most  effective  treatment  is  a  pill  containing 
dried  ox  gall  5  grains  and  aloin  1/4  grain,  at  night,  followed  in 
the  morning  by  a  saline.  Diarrhea  indicates  a  catarrhal  condi- 
tion of  the  bowel  generally  due,  in  the  aged,  to  excessive  food, 
occasionally  to  intestinal  fermentation  and  irritation.  In  the 
latter  case  the  stools  are  foul-smelling.  This  condition  can  be 
relieved  by  intestinal  antiseptics.  Fatty  diarrhea  and  steator- 
rhea indicate  involvement  of  the  pancreas  or  liver  or  perhaps 
of  both.  Beside  the  treatment  of  the  causative  condition 
the  fat  ingesta  must  be  diminished. 

Albuminuria  is  found  in  about  40  per  cent,  of  all  cases.  A 
trace  of  albumin  is  generally  present  in  the  urine  of  the  aged 
and  signifies  a  senile  contracted  kidney.  Unless  there  are 
symptoms  of  nephritis  (casts,  etc.),  or  when  albuminuria  appears 
suddenly  in  a  large  amount,  it  may  be  disregarded. 

Loss  of  virility  is  a  frequent  accompaniment  of  diabetes. 
This  is  probably  due  in  most  cases  to  the  male  climacteric 


DIABETES  MELLITUS  375 

which  occurs  about  the  end  of  the  fifth  decade  and  to  the  natural 
loss  of  virility  due  to  ageing.  It  has  no  significance  apart  from 
the  mental  depression  that  its  discovery  occasionally  produces. 
Nothing  should  be  done  for  it. 

Ocular  and  aural  disorders  sometimes  complicate  matters. 
Diabetic  cataract  may  improve  when  there  is  an  improvement 
in  the  general  disease  but  other  disorders  require  special  treat- 
ment directed  to  the  organ  involved. 

Pruritus  is  a  frequent  accompaniment  and  occasionally  it 
is  the  most  annoying  symptom.  Its  favorite  sites  are  about 
the  genitals  and  anus  where  it  is  often  associated  with  bromidro- 
sis  and  intertrigo  and  about  the  legs.  In  moist  locations  the 
treatment  must  be  directed  to  the  hyperhidrosis.  Stearate  of 
zinc  and  salicylic  acid  will  generally  relieve  the  excessive  secre- 
tion and,  if  the  itching  continues,  inunction  with  a  2  per  cent, 
cocaine  ointment,  using  lard  or  any  animal  fat  as  a  base,  will 
afford  temporary  relief.  This  ointment  can  also  be  used  in 
localities  where  the  skin  is  excessively  dry.  The  intensity  of 
the  pruritus  depends  upon  the  intensity  of  the  glycosuria. 
The  resistance  of  the  diabetic  to  infectious  disease,  especially 
to  septic  infection,  is  considerably  lowered,  the  opsonic  index 
being  approximately  one-third  lower  than  normal.  It  is  proba- 
ble too  that  the  sugar-laden  blood  is  a  better  culture  medium 
than  normal  blood.  We  find  consequently  streptococcus  and 
staphylococcus  infections  (in  the  form  of  furuncles,  carbuncles, 
abscess,  cellulitis  and  septic  gangrene)  frequently  attacking 
diabetics.  Dry  gangrene  occurring  in  diabetes  is  not  due  to 
that  disease  but  to  arteriosclerosis,  embolus  or  other  cause  that 
prevents  nutrition  of  the  part ;  the  greater  tendency  to  infection 
may,  however,  convert  a  dry  gangrene  into  a  purulent  one. 
Serum  therapy  in  the  form  of  a  vaccine  injecting  the  three 
varieties  of  the  staphylococcus  pyogenes,  aureus,  albus  and 
citreus,  has  been  found  curative  in  some  cases  of  diabetes  with 
infection  when  used  at  the  onset  of  the  complicating  lesion.  If 
this  fails,  local  treatment  must  be  instituted.  Furuncles 
generally,  and  occasionally  carbuncles  at  their  onset,  can  be 
aborted  if  a  needle  at  a  white  heat  is  thrust  into  the  center  of 
the  inflamed  elevation.  In  more  advanced  cases  of  carbuncle, 
cauterization  by  lunar  caustic  or  caustic  potash,  or  else  excision, 
is  necessary.     Carbuncle  in  the  aged  is  a  grave  disease  and  com- 


376  PATHOLOGICAL   OLD   AGE 

plete  excision  at  the  earliest  possible  moment  is  in  most  cases  the 
only  method  of  successfully  dealing  with  it. 

The  treatment  of  gangrene  in  diabetes  is  purely  surgical. 
The  serum  therapy  may  be  tried,  but  unless  there  is  rapid  and 
marked  improvement  no  time  should  be  lost  in  local  medication. 
The  danger  from  operative  procedure  is  less  than  the  danger 
from  septic  gangrene,  and  with  modern  methods  of  anesthesia 
and  surgery,  operations  upon  diabetics  are  no  longer  prejudged 
fatal. 

CEREBRAL  HYPEREMIA 

Cerebral  hyperemia  does  not  differ  in  the  aged  from  the 
same  condition  in  maturity.  Passive  congestion,  however,  is 
more  frequent,  being  often  due  to  the  impaired  jugular  circula- 
tion following  dilatation  and  tricuspid  disease. 

Active  hyperemia  in  the  senile  occurs  after  excitement, 
physical  exercise,  excessive  food,  coffee,  tea  or  alcohol.  It 
begins  with  a  sense  of  heat  in  the  head,  then  a  fulness  and  a 
beating  with  throbbing  temples,  spots  before  the  eyes,  buzzing 
in  the  ears,  vertigo  and  a  dulling  of  the  intellect  tending  to 
unconsciousness.  The  face  is  flushed  and  conjunctivae  are 
injected,  carotids  are  prominent  and  their  impulse  is  marked. 
The  attack  passes  away  in  a  few  minutes  if  the  cause  is  removed. 

Passive  hyperemia  is  a  chronic  condition  due  to  venous 
stasis.  It  may  occur  as  a  temporary  condition  if  the  cause  is  of  a 
temporary  nature,  as  the  pressure  of  a  tight  collar,  stooping, 
coughing,  etc.  In  the  permanent  condition  there  is  either  a 
valvular  disease  which  interferes  with  the  return  circulation,  or 
else  some  local  interference,  such  as  a  growth  pressing  upon  the 
jugular.  The  symptoms  are  persistent  headache,  drowsiness 
with  inability  to  sleep  when  lying  down,  vertigo,  flushed  face 
and  marked  prominence  of  the  jugulars.  The  arteries,  however, 
are  not  prominent. 

Treatment  of  cerebral  hyperemia  depends  upon  the  form  and 
the  cause,  which  must  be  removed  whenever  possible.  This 
can  generally  be  done  in  active  hyperemia  and  in  those  cases  of 
passive  hyperemia  or  venous  stasis,  the  causes  of  which  are  tem- 
porary, as  external  pressure.  In  cases  due  to  interference  with 
the  venous  circulation,  following  cardiac  disease,  or  the  pressure 


Tremorgraph — Paralysis  agitans,  left  hand.     (Neustaedter,  Med.  Rirord,  July  17,  1909.) 


Early  paralysis  agitans;  facial  as- 
pect characteristic.  Attitude  not  yet 
pronounced.  (Dr.  M.  Neustaedter's 
case.) 


PARALYSIS  AGITANS  377 

of  a  tumor,  we  must  resort  to  temporary  measures  to  lessen  the 
cerebral  circulation.  The  most  effective  measures  for  this  pur- 
pose are  hot  foot  or  sitz  baths.  Local  hyperemia  in  other  parts 
of  the  body  may  be  produced  by  mustard,  turpentine  stupes,  hot 
cloths,  cold  to  the  head,  etc.  If  there  is  danger  of  apoplexy, 
leeches  to  the  temples  or  cups  to  the  chest  and  back,  or  vene- 
section must  be  employed.  Drugs  are  useless.  Ergot  which  is 
serviceable  in  earlier  life  is  dangerous  in  the  aged  if  there  is 
cerebral  arteriosclerosis.  The  opiates  and  alcohol  increase  the 
hyperemia  and  chloral  is  dangerous  on  account  of  its  depressing 
action  upon  the  heart.  The  bromides  will  relieve  reflex  irrita- 
tion and  veronal  can  be  used  for  the  insomnia.  The  head  must 
be  kept  raised  and  the  feet  lowered  even  in  sleep.  Rapid  ca- 
tharsis will  sometimes  relieve  the  hyperemia  if  due  to  excessive 
food  or  coffee  or  alcohol.  The  coal-tar  preparations  acetphe- 
netidin,  acetanilid  and  similar  preparations  depress  the  heart 
and  leave  it  depressed. 

PARALYSIS  AGITANS 

Paralysis  agitans  is  a  progressive  motor  neurosis  of  middle 
and  advanced  age.  Neither  its  cause  nor  its  pathology  are 
known,  there  is  no  lesion  distinctive  of  the  disease,  and  of  the 
many  theories  advanced  for  its  pathogenesis,  none  is  satisfactory. 

Etiology. — The  basic  etiological  factor  is  unknown.  At  the 
present  moment,  we  ascribe  the  cause  for  anatomical  and  func- 
tional perversions  to  microorganisms  or  to  perverted  internal 
secretions.  It  has  been  suggested  that  paralysis  agitans  may  be 
due  to  atrophy  of  the  parathyroid  glands,  but  it  is  more  probably 
due  to  a  senile  change  in  the  motor  branches  of  the  spinal  nerves, 
although  no  change  in  them  has  been  demonstrated.  There  is 
generally  a  neurotic  tendency,  and  in  many  cases  an  etiological 
factor  affecting  the  brain  or  spinal  cord  can  be  discovered.  It 
may  be  shock,  fright,  intense  emotion,  prolonged  worry  or  fear, 
or  overwork.  In  some  cases  there  is  a  history  of  traumatism,  in 
others  an  acute  infectious  disease  preceded  the  advent  of  the 
paralysis  agitans.  Exposure  to  cold,  dampness,  unhygienic 
surroundings  and  poverty  have  been  given  as  the  exciting 
causes,  while  in  many  cases  no  cause  can  be  found. 

Pathology. — The  only  pathological  condition  present  in  every 


3y 8  PATHOLOGICAL   OLD   AGE 

case  is  an  arteriosclerosis  of  branches  of  the  spinal  arteries. 
This  has,  however,  been  found  in  cases  which  did  not  present 
the  symptoms  of  the  disease  and  on  the  other  hand  far  advanced 
paralysis  agitans  presented  on  autopsy  but  slight  vascular 
changes. 

Symptoms. — Paralysis  agitans  presents  a  characteristic 
clinical  picture.  Though  a  tremor  disease,  there  are  cases  with- 
out tremor,  cases  where  the  tremor  is  temporarily  absent,  but  the 
attitude  and  gait  are  always  present.  When  standing  the  patient 
is  bent  over  as  though  he  were  about  to  fall  forward,  his  knees 
and  elbows  are  bent,  the  hands  are  held  in  the  position  of  holding 
a  pen  or  rolling  a  pill.  The  walk  corresponds  with  the  attitude, 
the  bent  position  being  maintained,  and  there  is  a  forward  pitch 
with  short,  rapid,  shuffling  steps  which  must  be  kept  up  until  an 
obstruction  is  met  with.  In  the  early  stage  of  the  disease  the 
patient  can  stop  himself,  but  when  the  disease  is  well  advanced  he 
will  continue  to  go  forward  until  stopped  or  until  he  falls  and  if 
pushed  or  pulled  backward  he  will  continue  going  backward 
until  stopped.  The  attitude  is  due  partly  to  a  gradually  in- 
creasing rigidity  of  the  muscles  first  of  the  neck  and  back,  later 
of  the  extremities  and  face.  As  a  result  of  this  muscle  stiffness, 
voluntary  movements  become  difficult,  slow  and  deliberate. 
This  is  well  seen  in  the  hand  writing  which,  aside  from  the  trem- 
ulousness,  becomes  so  small  and  cramped  as  to  be  almost  illegible. 
Owing  to  the  rigidity  of  the  muscles  of  the  face  it  becomes  ex- 
pressionless, not  apathetic  as  in  dementia,  but  mask-like. 

The  tremor,  which  in  most  cases  is  the  earliest  and  most 
pronounced  symptom,  usually  begins  as  a  fine  trembling  in  one 
hand,  then  the  leg  of  the  same  side  is  affected,  later  the  opposite 
leg  and  lastly  the  other  hand.  The  order  is  not  regular  and  in 
some  cases  the  tremor  is  confined  to  the  hands  or  feet  alone,  or 
to  the  extremities  on  one  side.  Late  in  the  disease  the  head  and 
neck  muscles  are  affected  and  there  is  a  coarse  shaking  or  nod- 
ding of  the  head  with  tremor  of  the  lower  jaw  and  lips.  The 
tremor  rate  is  from  four  to  seven  per  second  but  it  may  be  tem- 
porarily controlled  by  the  will  and  it  ceases  during  sleep.  Ex- 
citement and  fatigue  do  not  increase  the  rate  but  they  increase 
the  extent  of  the  oscillations  until  they  become  a  coarse  tremor 
or  shake. 

"Paralysis  agitans  sine  tremore, "  paralysis  agitans  without 


PROGRESSIVE  BULBAR  PARALYSIS  379 

tremor,  is  occasionally  met  with.  The  name  is  a  misnomer,  for 
while  there  is  progressive  weakness  there  is  never  complete  loss 
of  power,  and  without  tremor  there  is  no  agitation. 

In  these  cases  there  is  progressive  muscle  rigidity,  generally 
marked  on  one  side  and  but  slight  on  the  other,  and  later  the 
characteristic  attitude  appears.  A  peculiarity  of  the  gait  is  an 
apparent  inability  or  lack  of  energy  to  make  the  first  step  when 
intending  to  walk.  It  then  requires  some  powerful  mental 
impression  as  a  threat,  or  some  external  impetus,  to  start  him. 

Diagnosis. — When  the  disease  has  so  far  advanced  that  the 
characteristic  attitude  becomes  a  prominent  feature  error  in 
diagnosis  is  impossible. 

Before  this  time  it  may  be  mistaken  for  senile  tremor  (see 
Senile  Tremor)  and  other  tremor  diseases.  Multiple  sclerosis  and 
hysteria  are  extremely  rare  in  old  age.  The  different  character 
of  the  tremor  and  the  absence  of  muscle  stiffness  will  exclude 
these  and  also  the  toxic  tremors  (lead,  mercury,  alcohol,  etc.). 

Treatment. — The  disease  is  incurable.  It  progresses  slowly 
and  while  cases  have  succumbed  within  a  year  after  the  initial 
symptoms  were  observed,  the  ordinary  duration  is  from  five  to 
fifteen  years. 

Hyoscine  in  1/300-grain,  or  hyoscy amine  sulphate  in  1/100- 
grain,  doses,  hypodermically,  will  relieve  the  tremor  and  muscle 
stiffness,  but  the  dose  must  be  constantly  increased  and  the  drug 
finally  discontinued  when  toxic  effects  appear.  Duboisin  may 
then  be  substituted  and  given  in  doses  of  1/150  grain,  gradually 
increased.  Hydrotherapy  and  electrotherapy  are  of  temporary 
utility  in  arresting  the  progress  of  the  disease.  Arsenic  has  a 
more  permanent  effect  and  should  be  given  until  the  physiolog- 
ical effects  of  the  drug  compel  its  discontinuence.  Nux  vomica 
which  has  been  recommended  as  a  tonic  seems  to  intensify  the 
tremor  and  muscle  cramps.  When  the  patient  becomes  bed- 
ridden measures  must  be  employed  to  prevent  hypostatic 
congestion  and  edema. 

PROGRESSIVE  BULBAR  PARALYSIS 

Glossopharyngolabial  paralysis  is  a  rare  disease,  occurring 
most  frequently  in  advanced  life.  It  is  a  symmetrical  paralysis 
affecting  the  muscles  of  the  lips,  tongue,  palate,  pharynx, 
larynx  and  the  muscles  of  mastication. 


380  PATHOLOGICAL    OLD    AGE 

Etiology. — The  cause  is  unknown.  Supposed  causes  are 
shock,  strong  emotions,  cold,  overexertion  of  the  muscles  supplied 
by  the  hypoglossal  and  glossopharyngeal  nerves,  injury  and 
infections. 

Pathology. — There  is  a  degeneration  of  the  motor  nuclei  of 
the  medulla  and  pons,  the  ganglionic  cells  atrophy,  the  hypo- 
glossal, glossopharyngeal,  facial,  vagus,  accessory  and  sometimes 
trifacial  motor  trunks  are  degenerated  and  the  pyramidal  tracts 
of  the  cord  are  occasionally  involved.  In  some  cases  the  ante- 
rior horns  are  atrophied  and  the  lateral  columns  are  degenerated, 
and  we  find  the  same  lesions  as  observed  in  progressive  muscular 
atrophy  and  amyotrophic  lateral  sclerosis,  but  the  symptoms  of 
these  diseases  are  absent  or  appear  late. 

Symptoms. — The  symptoms  are  a  progressively  increasing 
difficulty  in  speech,  phonation,  chewing  and  swallowing,  later 
difficulty  in  respiration,  a  fibrillary  tremor  of  the  tongue  and 
muscles  of  mastication  and  waste  of  the  muscles  involved.  The 
speech  becomes  difficult,  due  to  gradual  paralysis  of  the  tongue, 
and  the  Unguals  are  slurred  over.  Later  the  same  difficulty  arises 
with  the  labials  and  the  speech  becomes  indistinct,  obscure  and 
finally  incomprehensible.  At  the  same  time  progressive  paraly- 
sis of  the  larynx  and  vocal  cords  makes  phonation  difficult  and 
the  voice  becomes  weak,  finally  dropping  to  a  monotonous 
hoarse  whisper.  The  tongue  slowly  loses  its  motility  and  be- 
comes completely  paralyzed.  Owing  to  the  paralysis  of  the  lips, 
the  mouth  cannot  be  closed  and  saliva  drivels  out.  The  patient 
is  unable  to  whistle.  The  soft  palate  drops,  further  interfering 
with  speech  and  deglutition.  Weakening  of  the  muscles  of 
mastication  makes  it  impossible  to  move  the  jaws  from  side  to 
side  and  the  paralysis  of  the  muscles  of  deglutition  prevents  swal- 
lowing, the  food  remaining  as  a  bolus  in  the  posterior  part  of  the 
mouth  while  fluids  run  back  through  the  nostrils.  When  the 
disease  is  fully  developed  the  lower  half  of  the  face  is  expression- 
less, the  lower  lip  and  corners  of  the  mouth  hang  down  and  the 
countenance  presents  a  very  peculiar  appearance,  the  lower  part 
being  paralyzed  while  the  upper  part  is  active.  The  mind  is 
unimpaired.  There  is  usually  tachycardia,  with  dyspnea  and 
with  exaggerated  facial  reflexes. 

Progressive  bulbar  paralysis  is  distinguished  from  hemor- 
rhage, thrombosis,  and  embolism  in  the  medulla,  by  its  slow 


PSEUDOBULBAR  PARALYSIS  38 1 

advent,  the  other  conditions  appearing  suddenly.  Tumors  in 
the  medulla  produce  more  extensive  paralysis  beside  intense 
headaches. 

Treatment. — There  is  no  known  treatment,  death  usually 
occurring  in  a  few  years  from  asthenia.  It  may  occur  earlier, 
however,  from  aspiration  pneumonia,  respiratory  paralysis  or 
other  complicating  disease.  Strychnine,  arsenic,  iodides,  ni- 
trate of  silver,  the  galvanic  and  faradic  currents  have  all  been 
used  with  apparent  momentary  improvement,  but  no  cure  has 
ever  been  reported. 

ACUTE  BULBAR  PARALYSIS 

This  is  a  form  of  apoplexy  which  resembles  the  progressive 
bulbar  paralysis  in  its  clinical  picture  but  differs  from  the  latter 
in  its  sudden  onset.  It  occurs  as  the  result  of  a  hemorrhage  into 
the  pons  by  breaking  down  of  the  tissue  after  thrombosis  or 
embolism  in  the  basilar  or  vertebral  artery,  or  in  one  of  their 
branches  had  taken  place.  Thrombosis  produces  premonitory 
symptoms  such  as  vertigo,  tinnitus,  headache,  insomnia,  etc. 
The  onset  of  the  disease  is  abrupt.  A  momentary  vertigo  and 
vomiting  is  followed  by  convulsions.  When  these  pass  away 
there  remains  a  glossopharyngolabial  paralysis  with  all  the 
symptoms  described  under  progressive  bulbar  paralysis,  and 
frequently  also  a  hemiplegia  or  paraplegia.  The  paralysis  of 
the  facial  muscles,  and  muscles  of  deglutition,  mastication  and 
speech,  is  not  always  symmetrical,  and  where  there  has  been 
an  extensive  extravasation  of  blood  the  muscles  of  the  upper 
part  of  the  face,  including  the  motor  muscles  of  the  eyes,  may 
become  involved.  The  disease,  when  extensive,  is  rapidly  fatal; 
in  mild  cases  recovery  is  possible. 

Treatment  as  for  apoplexy. 

PSEUDOBULBAR  PARALYSIS 

In  this  disease  the  symptoms  of  bulbar  paralysis  set  in  after 
several  apoplectic  attacks  during  which  other  forms  of  paralysis 
had  occurred.  The  ordinary  lesions  of  cerebral  apoplexy, 
cerebral  hemorrhages,  are  found,  and  in  most  cases  there  are 
minute  extravasations  in  the  pons  and  medulla.     The  disease 


382  PATHOLOGICAL   OLD   AGE 

when  fully  developed  presents  the  symptoms  of  cerebral  arterio- 
sclerosis, cerebral  apoplexy  and  progressive  bulbar  paralysis 
and  is  really  a  combination  of  the  three  diseases.  The  fifth 
group  takes  in  diseases  which  do  not  fit  in  any  of  the  preceding 
groups. 

DISEASES  UNINFLUENCED  BY  AGE  OR  RARE  IN 

OLD  AGE 

INFECTIOUS  DISEASES 

The  resistance  to  bacterial  influences  is  apparently  greater 
in  old  age  than  in  earlier  life.  This  is  opposed  to  the  general 
view  that  resistance  is  lowered  in  the  aged,  but  the  simple  fact 
that  infectious  diseases  rarely  attack  old  persons  even  in  epidem- 
ics, would  seem  to  substantiate  this  statement.  Whether  this 
resistance  is  due  to  an  increase  in  opsonins,  more  active  phago- 
cytosis or  a  change  in  the  body  tissues  whereby  the  tissues 
become  an  unsuitable  field  for  the  propagation  of  the  germs, 
is  unknown.  Other  possible  explanations  are  an  inherent 
resistance  in  senile  cells,  a  lower  body  temperature,  less  exposure, 
etc.  The  only  diseases  of  this  character  that  are  relatively  as 
frequent  in  the  aged  as  in  maturity  are  erysipelas,  variola,  influ- 
enza, typhus  and  cholera.  The  frequency  of  erysipelas  on  the 
lower  limbs  is  readily  accounted  for  by  the  presence  of  surface 
lesions,  such  as  excoriations,  scratches,  eczema  and  ulcers  in 
that  locality.  The  frequency  of  influenza  is  due  to  the  preva- 
lence of  chronic  bronchitis,  the  impaired  mucous  membrane 
being  a  suitable  field  for  the  growth  of  the  pathogenic  bacillus. 
That  variola  frequently  attacks  the  aged  in  epidemics  is  proba- 
bly due  to  the  fact  that  the  immunity  secured  by  vaccination 
in  childhood  wears  off  in  the  course  of  years  and  the  aged  are 
hence  more  susceptible  than  younger  persons  who  have  been 
more  recently  vaccinated.  The  greater  susceptibility  of  the 
old  to  typhus  is  probably  due  to  the  general  debility  which 
lessens  resistance  to  this  disease  and  the  same  cause  with  the 
senile  changes  in  the  intestines  will  account  for  the  relative 
frequency  of  cholera  in  the  aged.  Cholera  and  typhus  are 
infrequent  in  this  country,  however,  and  for  this  reason  cases 
among  the  aged  here  are  of  the  greatest  rarity. 


INFECTIOUS  DISEASES  383 

The  acute  infectious  diseases  when  occurring  in  the  aged 
present  some  peculiarities.  They  do  not  run  a  typical  course 
nor  present  a  typical  temperature  curve,  and  the  temperature  is 
rarely  as  high  as  in  maturity.  In  the  eruptive  diseases  the 
eruption  is  milder  and  may  be  absent,  but  constitutional  symp- 
toms are  usually  graver  and  death  frequently  ensues  in  cases 
which  are  apparently  mild.  In  the  graver  diseases  like  typhus, 
cholera  and  variola,  death  usually  occurs  within  a  few  days 
after  the  onset  of  the  disease.  In  the  chronic  infectious  diseases 
and  in  those  that  do  not  run  a  definite  course  the  symptoms  are 
usually  milder  but  more  persistent  than  in  earlier  life. 

It  is  assumed  that  the  physician  is  familiar  with  the  ordinary 
etiological  factors,  symptoms,  signs  and  therapeutic  measures 
employed  in  infectious  diseases  in  maturity.  Where  differences 
in  these  factors  in  maturity  and  senility  exist,  they  will 
be  described,  but  otherwise  the  etiology,  symptoms,  signs  and 
treatment  will  be  omitted.  Such  rare  diseases  as  malta  fever, 
miliary  fever,  etc.,  and  diseases  which  are  not  known  to  occur 
in  senility  such  as  rotheln,  varicella,  etc.,  will  receive  no  further 
consideration.  In  the  differential  diagnosis  between  diseases 
giving  similar  symptoms,  only  pathognomonic  symptoms  and 
signs  where  such  exist,  or  else  a  few  cardinal  symptomatic  differ- 
ences will  be  noted.  As  a  rule  the  temperature  range  of  acute 
infectious  diseases  is  lower  in  the  aged,  the  eruption  in  the 
exanthemata  is  lighter,  more  scattered  and  the  spots  fewer  in 
number.  They  come  on  later,  and  whereas  they  appear  in 
successive  crops  in  maturity,  in  old  age  there  is  only  a  single  crop. 
The  cerebral  and  nervous  symptoms  are  usually  much  more 
pronounced  than  in  earlier  life,  the  prostration  is  more  severe, 
complications  are  more  frequent,  and  the  grave  diseases,  like 
typhoid  and  variola,  are  more  fatal.  In  diseases  in  which  the 
bronchial  mucous  membrane  is  seriously  involved,  bronchial 
and  pulmonary  complications  frequently  end  in  death.  Many 
cases  are  followed  by  incomplete  recovery,  mental  and  physical 
impairment,  and  foci  susceptible  to  later  diseases  are  retained. 

Scarlatina  has  been  reported  in  the  aged.  It  appears  in  a 
mild  form,  however,  and  the  temperature  is  but  slightly  elevated; 
the  eruption  is  light  and  the  complications  of  early  life  are  usually 
absent  or  are  mild.  The  pharynx  and  tonsils  may  be  reddened, 
but  there  is  never  the  scarlatinal  diphtheria  nor  any  cervical 


384  PATHOLOGICAL   OLD    AGE 

gland  involvement,  and  rarely  the  typical  strawberry  tongue. 
Desquamation  sets  in  early,  usually  before  the  end  of  the  first 
week.  Cases  of  scarlatina  sine  exanthemate  also  occur  in  the 
aged.  These  cases  present  the  buccal  and  pharyngeal  lesions 
with  fever  but  not  the  rash.  Desquamation  occurs  as  in  ordi- 
nary scarlatina.  The  prophylactic  treatment  is  as  in  childhood. 
The  only  treatment  during  the  disease  is  rest,  the  reduction  of 
temperature,  if  high,  by  means  of  warm  baths,  maintenance 
of  the  strength  of  the  heart  and  of  the  organism  as  a  whole,  and 
hygienic  and  dietetic  measures.  As  a  mouth  wash  and  gargle 
nothing  equals  a  solution  of  peroxide  of  hydrogen. 

Measles  occur  rarely  in  the  aged  and  do  not  differ  from 
the  same  disease  in  earlier  life,  though  they  appear  in  a  much 
milder  form,  the  conjunctival  symptoms  are  milder,  but  the 
irritation  of  the  bronchial  mucous  membrane  is  more  severe 
and  may  lead  to  a  bronchopneumonia.  This  is  the  only  danger 
in  measles  but  it  is  ever  present  until  the  disease  has  entirely 
disappeared,  and  it  forms  the  basis  of  the  usually  unfavorable 
prognosis.  The  disease  itself  is  mild,  the  rash  is  slight,  with  but 
little  elevation  of  temperature,  but  there  is  a  profound  feeling 
of  malaise.  The  symptoms  diminish  in  severity  after  the  first 
day  and  may  disappear  entirely  within  two  or  three  days.  If 
there  is  an  old  bronchitis  present,  a  capillary  bronchitis  by 
extension  is  almost  unavoidable.  Cardiac  disease  or  arterio- 
sclerosis complicating  measles  increases  the  asthenia  and  makes 
the  prognosis  more  unfavorable.  The  treatment  is  hygienic 
and  symptomatic.  If  there  is  conjunctivitis  the  room  should 
be  darkened.  For  the  irritating  cough  with  which  the  disease 
usually  begins  codein,  heroin  or  dionin  should  be  given  and 
menthol  and  eucalyptol  should  be  inhaled.  The  disease  being 
usually  of  short  duration,  tonics  and  cardiac  stimulants  are  not 
required.  The  danger  of  extension  of  the  bronchitis  to  the 
vesicles  can  be  lessened  by  the  inhalation  of  steam  through  an 
inhaler. 

Diphtheria  may  occur  in  the  aged  and  is  then  usually  so  mild 
in  its  subjective  symptoms  that  it  may  pass  unnoticed.  There 
may  be  little  or  no  elevation  of  temperature,  no  pain,  swelling 
or  redness  of  the  tonsil,  nor  any  other  symptom  than  the  exudate. 
The  exudate  does  not  differ  from  the  diphtheritic  exudate  of 
early  life,  but  it  is  more  tenacious  and  may  persist  for  weeks, 


DIPHTHERIA  385 

in  spite  of  the  use  of  antitoxin.  The  mildness  of  the  symptoms 
is,  however,  a  source  of  danger  as  its  presence  in  the  fauces  may 
be  overlooked  until  the  disease  has  advanced  to  the  larynx. 
Laryngeal  diphtheria,  which  is  almost  always  fatal,  begins 
with  hoarseness,  cough  and  a  feeling  of  irritation  in  the  larynx 
as  though  there  were  a  bit  of  tenaceous  mucus  which  the  patient 
is  unable  to  bring  up.  The  exudate  increases  downward  over 
the  trachea,  causing  spasmodic  contractions,  dyspnea,  cyanosis 
and  death.  In  some  cases  the  cough  loosens  a  fragment  of 
exudate  which  drops  into  the  bronchus,  blocking  a  tube  and  caus- 
ing sudden  dyspnea  and  suffocation.  Death  is  usually  not  due 
to  the  virulence  of  the  diphtheria  bacillus  but  to  the  local  obstruc- 
tion, or  to  exhaustion  from  coughing.  In  gangrenous  diphtheria 
a  gangrenous  ulcer  appears  upon  the  tonsil,  sometimes  within 
a  day  or  two  after  the  initial  malaise,  the  opposite  side  is  rapidly 
involved  and  the  adjoining  tissue  in  the  pharynx,  uvula  and  soft 
palate  may  also  become  gangrenous.  There  is  an  abundant 
secretion  of  foul-smelling  pus,  sometimes  mixed  with  blood, 
grave  constitutional  symptoms  appear,  such  as  extreme  exhaus- 
tion, weak,  irregular  pulse,  shallow  breathing,  headache  and 
albuminous  urine,  containing  casts,  etc.  There  is  rarely  any 
fever  or  involvement  of  the  cervical  glands.  The  disease  is 
almost  always  rapidly  fatal.  The  diagnosis  of  diphtheria  is 
simple  and  depends  upon  the  presence  of  the  pathogenic  bacillus. 
The  usual  antitoxin  treatment  applies  to  the  aged  exactly  the 
same  as  to  "younger  individuals,  but  it  is  never  necessary  to 
exceed  3000  units,  given  in  a  single  dose  except  in  laryngeal 
cases.  Larger  or  repeated  doses  will  not  hasten  the  removal  of 
the  exudate  which  may  persist  for  weeks,  while  a  single  dose 
of  1000  units  may  suffice  to  prevent  laryngeal  involvement. 
Diphtheria  antitoxin  is  useless  in  gangrenous  diphtheria,  the 
condition  being  due  to  a  mixed  infection  in  which  a  virulent 
strain  of  streptococci  or  staphylococci  is  responsible  for  the 
gangrene.  A  mixed  or  autogenous  vaccine  is  required  in  these 
cases.  In  laryngeal  diphtheria  antitoxin  should  be  used  in 
doses  commensurate  with  the  severity  of  the  symptoms. 

For  the  removal  of  the  membrane  a  10  per  cent,  solution  of 

papayotin  or  trypsin  will  give  the  most  rapid  result.     It  should 

be  swabbed  over  the  patch  every  hour  or  two.     The  membrane 

will  re-form  but  the  frequent  application  will  prevent  the  exten- 

25 


386  PATHOLOGICAL    OLD    AGE 

sion  of  the  growth  to  the  larynx.  A  solution  of  peroxide  of 
hydrogen  can  be  employed  locally,  but  if  either  of  the  enzymes 
is  employed  the  peroxide  of  hydrogen  must  be  used  afterward, 
never  before  the  other.  Lactic  acid  will  also  remove  membrane. 
Chlorate  of  potash  is  useless  in  diphtheria.  The  hygienic  and 
dietetic  regulations  need  no  special  consideration,  except  that 
food  should  not  be  taken  hot,  and  precautions  should  be  taken  to 
prevent  the  spread  of  the  disease.  Internal  medication  is  not 
required  except  where  complicating  symptoms  appear. 

Whooping  cough  differs  in  some  minor  factors  from  the  dis- 
ease in  infancy.  After  a  primary  catarrhal  period  lasting  from 
two  to  three  weeks,  during  which  there  is  a  bronchial  catarrh, 
constantly  increasing  in  intensity,  the  second  period  sets  in 
with  a  convulsive  cough.  The  paroxysms  of  coughing  are  simi- 
lar to  those  of  infancy,  but  they  occur  more  frequently  during 
meals,  the  movements  of  deglutition  apparently  provoking  the 
attack.  During  the  cough  of  the  aged,  the  characteristic  whis- 
tling inspiration  observed  in  infants  is  absent  and  vomiting  which 
is  a  frequent  accompaniment  of  the  cough  in  the  young  does  not 
occur  in  the  old.  After  an  indefinite  period  the  spasmodic  at- 
tacks cease  and  a  bronchial  catarrh  is  retained  which  forms  the 
third  period  of  pertussis  in  the  aged.  Complications  are  rare, 
and  are  almost  always  due  to  the  irritation  of  the  larynx  and  the 
strain  of  coughing.  In  rare  cases  brochopneumonia  will  occur 
during  the  disease,  or  may  follow  it.  The  treatment  is  as  in 
infancy.  A  change  of  climate  will  sometimes  hasten  the  cure. 
The  medicinal  measures  usually  given  in  infancy  must  be  given 
in  increased  doses  in  senility,  but  vasoconstrictors  must  be 
avoided. 

Mumps  has  been  reported  in  the  aged.  The  essential  fea- 
tures of  the  disease  are  the  same  as  those  of  earlier  life  but  the 
orchitis  which  generally  accompanies  the  disease  in  maturity 
does  not  appear  in  old  age.  The  disease  is  usually  mild,  but  a 
few  cases  have  been  reported  in  which  death  had  occurred  soon 
after  cerebral  symptoms,  delirium  and  coma  appeared.  The 
treatment  is  purely  symptomatic  unless  suppuration  occurs  when 
a  free  incision  is  indicated.  The  inunction  with  a  5  per  cent, 
solution  of  oleate  of  mercury  may  shorten  the    inflammation. 

Malaria  is  infrequent  in  the  aged,  either  as  a  primary  attack, 
or  as  a  recrudescence  of  an  earlier  one.     The  disease  differs 


YELLOW  FEVER  387 

slightly  in  its  symptoms  from  that  of  earlier  life.  The  tempera- 
ture is  rarely  above  1030,  and  where  the  first  attack  occurs  late 
in  life,  there  is  no  apparent  enlargement  of  the  spleen.  Other 
symptoms,  such  as  headache,  malaise,  aches  in  the  bones,  joints 
and  back,  thirst,  anorexia,  etc.,  may  be  aggravated.  Remittent 
fever  and  pernicious  malaria  are  extremely  rare  and  the  latter  is 
almost  always  rapidly  fatal.  The  ordinary  intermittent  fever  is 
readily  recognized  by  the  regularity  of  its  appearance  in  the 
tertian  or  quotidian  form.  In  all  cases  Osier's  dictum,  "an 
intermittent  fever  that  resists  quinine  is  not  malaria,"  holds 
good. 

Chronic  malaria  or  malarial  cachexia  follows  repeated  attacks 
of  one  of  the  acute  forms  and  is  usually  fatal  in  the  aged.  The 
course  and  treatment  of  malaria  is  the  same  as  in  younger  in- 
dividuals. In  the  severe  forms  of  remittent  and  pernicious  fever 
quinine  alone  is  of  little  service,  except  to  reduce  the  temperature 
and  this  is  rarely  high  in  the  aged.  The  quinine  should  be  given 
in  these  cases  combined  with  gr.  1/40  of  arsenic  three  times 
daily  or  with  methylene  blue  in  2 -grain  doses,  while  other  symp- 
toms should  be  treated  symptomatically. 

Yellow  fever  appears  infrequently  and  when  it  does  occur, 
it  presents  the  same  symptoms  and  takes  the  same  course  as  in 
younger  individuals.  It  is  probable  that  the  comparative  rarity 
of  yellow  fever  and  primary  attacks  of  malaria  in  the  aged  is  due 
to  the  character  of  the  senile  skin  which  makes  it  less  attractive 
to  the  pathogenic  mosquito  than  the  skin  of  younger  individuals. 
The  temperature  in  yellow  fever  is  rarely  high,  and  vomiting  may 
be  absent  during  the  entire  disease,  while  the  icterus  is  not  as 
pronounced  as  in  younger  individuals,  probably  due  to  the  darker 
and  more  weather-beaten  skin.  Other  symptoms  such  as  head- 
ache, pain  in  the  bones,  joints,  back  and  epigastrium,  occur  as  in 
maturity.  The  stage  of  initial  fever  may  be  prolonged,  the 
remission  short  and  the  reaction  protracted.  Most  deaths  occur 
during  the  stage  of  reaction  and  are  due  to  profound  impairment 
of  the  heart,  kidneys,  or  liver.  Some  deaths  are  due  to  pulmon- 
ary edema  following  hypostatic  congestion,  or  to  general  ex- 
haustion. The  diagnosis  is  readily  made  by  the  distinguishing 
features  pointed  out  by  Guiteras,  the  facies,  early  albuminuria 
and  a  slowing  pulse,  with  a  constant  or  rising  temperature. 
There  is  a  high  hemoglobin  percentage,  and  the  blood  count 


388  PATHOLOGICAL    OLD   AGE 

shows  an  increased  number  of  red  cells  and  diminished  leuko- 
cytosis. 

The  treatment  of  yellow  fever  is  symptomatic  and  hygienic. 
Quinine  has  apparently  no  other  effect  than  to  reduce  the  tem- 
perature, and  for  this  purpose  it  is  the  most  reliable  antipyretic 
we  have.  The  bowels  should  be  thoroughly  cleared,  using, 
preferably,  castor  oil;  calomel  should  not  be  used.  As  intestinal 
antiseptics,  we  can  employ  salol  and  the  sulphocarbolates. 
Nothing  will  stop  the  black  vomit  when  it  occurs,  but  the  ten- 
dency to  vomit  can  be  diminished  by  small  doses  of  cocaine. 
Should  a  reaction  set  in,  the  bile  salts  can  be  given  to  replace  the 
diminished  bile,  hot  fomentations  over  the  kidneys  and  saline 
diuretics  largely  diluted  should  be  employed  in  anuria,  and 
heart  tonics  where  the  heart  becomes  weak,  as  it  usually 
does  in  yellow  fever.  Spartein  is  the  proper  drug  when  the 
heart  becomes  weak  and  slow.  Concentrated  and  predi- 
gested  foods  should  be  given  throughout  the  disease  and 
during  convalescence. 

Dysentery  does  not  differ  in  its  essential  features  from  the 
dysentery  of  earlier  life.  Both  the  bacillary  and  the  amebic 
forms  occur  in  the  aged,  the  two  forms  presenting  the  same 
symptoms.  The  bacillary  form  generally  begins  with  chills  and 
a  slight  elevation  of  temperature,  after  which  the  intestinal 
symptoms  appear.  These  are  frequent,  small,  painful  dejections, 
abdominal  cramps,  tenesmus  and  straining  and  the  passage  of 
mucus  and  blood.  There  is  rapid  prostration  and  emaciation, 
great  thirst  and  often  rapid  exhaustion.  The  disease  is  more 
fatal  in  the  aged  than  in  younger  individuals  and,  unless  con- 
trolled, a  fatal  issue  may  be  reached  in  a  few  days.  Since  the 
introduction  of  the  antidysenteric  serum  the  death  rate  has 
been  greatly  lowered.  The  amebic  form  is  usually  slower  in 
its  onset  than  the  other,  it  is  more  protracted  and  unless  death 
results  from  toxemia,  or  from  perforation  of  the  bowel,  it 
usually  passes  into  the  chronic  form  of  dysentery.  In  this 
form  there  are  remissions  and  exacerbations,  the  remissions 
being  usually  marked  by  alternating  constipation  and  diarrhea. 
During  an  exacerbation  there  is  a  return  of  the  usual  symptoms 
of  acute  dysentery.  During  the  remissions  there  may  be  a 
lienteric  diarrhea,  or  there  may  be  semisolid  or  fluid  stools 
usually  containing  mucus,   but  rarely  blood,   while  tenesmus 


DYSENTERY  389 

and  straining  may  be  absent.  In  this  form  of  dysentery  there 
s  progressive  emaciation,  the  individual  becomes  weaker  and 
dies  from  exhaustion,  the  fatal  issue  being  sometimes  reached 
in  a  few  weeks;  more  often,  however,  it  does  not  ensue  until 
several  months  or  a  year  or  more  have  elapsed.  Complete 
recovery  is  extremely  rare  in  advanced  life.  Numerous  com- 
plications arise  in  the  course  of  acute  and  chronic  dysentery. 
These  are  due  in  part  to  the  loss  of  blood  and  water,  in  part 
to  the  toxemia  and  septic  infection  and  in  part  to  the  local 
destruction  of  tissue.  The  gangrenous  process  may  extend 
through  the  wall  of  the  bowel  and  cause  perforation  and  speedy 
death.  Hepatic  abscess  frequently  follows  amebic  dysentery 
and  abscess  and  gangrene  in  other  tissues  are  occasionally 
observed.  Septic  inflammation  may  occur  in  any  tissue  and 
other  bacterial  diseases  are  sometimes  associated  with  it. 
For  the  bacillary  dysentery  we  have  an  antidysenteric  serum 
which  is  curative  in  most  cases  but  it  is  useless  in  the  amebic 
form.  In  addition  to  the  serum,  other  therapeutic  measures 
are  employed  to  produce  a  cessation  of  the  discharges,  relieve 
the  distressing  symptoms,  and  maintain  the  strength  of  the 
patient.  The  first  indication  is  to  clear  the  bowel  with  castor 
oil.  After  this  has  been  accomplished  the  Cautani's  enteroclysis 
solution  should  be  employed  as  described  under  cholera.  For 
the  relief  of  the  diarrhea  we  can  use  tannalbin,  the  sulphate  or 
arsenite  of  copper,  zinc  sulphate,  nitrate  of  silver,  or  any  of  the 
metallic  astringents.  Ipecac  is  probably  the  oldest  and  best 
drug  for  the  control  of  the  diarrhea.  The  dose  is  10  to  15 
grains  every  hour  for  four  hours,  given  preferably  in  milk. 
As  this  may  have  an  emetic  effect,  the  patient  must  remain 
strictly  in  the  recumbent  position  and  10  minims  of  tincture 
of  opium  should  be  given  before  starting  the  ipecac  treatment. 
If  there  is  pus  in  the  discharges,  salol  or  the  sulphocarbolates 
should  be  given  with  the  astringent.  Belladonna  given  in  a 
suppository  will  generally  relieve  the  tenesmus  and  morphine 
may  be  used  to  relieve  pain  and  insomnia.  Magnesium  sul- 
phate often  relieves  the  distressing  symptoms.  The  various 
complications  require  appropriate  medication.  The  dietary 
treatment  is  important,  as  improper  food  will  aggravate  the 
disease.  The  food  should  be  liquid  and  concentrated,  corre- 
sponding with  the  character  of  the  stools.     If  the  stools  are 


390  PATHOLOGICAL   OLD   AGE 

watery    the    food    should    be    liquid.      With    semisolid    stools 
give  mushy  food,  and  no  solid  food  till  stools  are  natural. 

Plague  does  not  occur  in  the  United  States  except  in  isolated 
cases  of  immigrants  coming  from  plague  infested  countries. 
In  countries  where  it  does  prevail  it  is  seldom  found  among  the 
aged,  and  when  they  are  attacked,  it  appears  in  a  milder  form 
than  it  does  in  maturity.  According  to  Ortner  the  death  rate 
is  not  higher,  indeed  it  may  be  lower  than  in  earlier  life.  This 
would  tend  to  confirm  the  view  that  the  aged  organism  is  more 
resistant  to  infection  than  the  younger. 

Cholera  when  epidemic,  attacks  the  aged  as  rapidly  as 
younger  individuals  and  is  much  more  fatal,  death  occurring 
in  almost  every  case,  even  when  the  symptoms  are  mild.  The 
disease  does  not  differ  in  its  essential  features  from  the  disease 
in  maturity.  The  period  of  incubation  may  be  prolonged,  but 
the  onset  and  course  of  the  disease  are  as  in  younger  individuals. 
The  discharges  and  vomiting  soon  induce  profound  prostration 
and  collapse.  In  some  cases  collapse  sets  in  before  the  choleric 
rice-water  diarrhea  has  appeared;  in  most  cases  collapse  occurs 
during  the  algid  stage.  Few  aged  patients  survive  this  stage 
and  most  of  those  that  do,  succumb  to  a  succeeding  typhoid 
condition. 

There  is  no  specific  treatment  for  cholera  and  all  our  efforts 
must  be  directed  to  counteract  threatening  symptoms.  The 
vomiting  may  sometimes  be  checked  by  cocaine  in  1/8-  to  1/4- 
grain  doses,  chloroform  in  3-minim  doses  or  morphine  in  1/8- 
grain  doses,  hypodermically.  The  usual  treatment  for  the  diar- 
rhea is  first  a  large  dose  of  castor  oil  followed  two  hours  later  by 
10  minims  of  tincture  of  opium.  Cautani's  enter ocly sis  solution 
for  irrigation  of  the  bowels  should  be  used  three  or  four  times  a 
day.  This  solution  consists  of  tannic  acid  21/2  drams,  tincture 
of  opium  30  minims,  mucilage  of  acacia  3  ounces,  to  4  pints  of 
water.  It  is  injected  slowly  at  a  temperature  of  1050.  For 
the  muscle  cramps,  menthol  and  chloroform  liniment,  combined 
with  massage,  may  give  temporary  relief.  The  usual  heart 
tonics,  camphor,  caffeine,  cactin,  etc.,  must  be  used  from  the 
onset,  reserving  strychnine  for  the  inevitable  emergency  during 
the  algid  stage  or  earlier.  Dermoclysis  and  intravenous  injec- 
tions of  normal  saline  solution  are  used  when  collapse  sets  in. 
Salol  and  the  sulphocarbolates   should   be   used  as  intestinal 


VARIOLA  391 

disinfectants  from  the  onset  of  the  disease.  Concentrated  and 
predigested  foods  are  necessary. 

Cholerine,  a  mild  cholera  with  slight  muscle  cramps,  little 
or  no  vomiting  and  colored  diarrheal  discharges,  is  treated  like 
the  grave  form. 

Variola  in  the  aged  rarely  follows  the  classical  course.  The 
prodromal  period  is  more  severe  and  prolonged.  The  cerebral 
symptoms  simulate  early  meningitis,  and  may  proceed  to 
delirium  and  coma.  There  is  always  a  weak,  rapid  pulse  and 
often  shallow  rapid  respirations.  The  initial  symptoms  are 
slight  chills,  rapid  rise  in  temperature,  prostration  and  pain  in 
the  lumbar  region.  The  initial  eruption  is  usually  absent  and 
the  true  eruption  of  variola  appears  as  rose-colored  macules, 
few  in  number  and  more  scattered  than  in  earlier  life.  Few  of 
these  macules  proceed  beyond  the  papular  stage  and  fewer 
still  become  fully  developed  variola  pustules.  The  disease  is 
protracted  in  the  aged,  and  in  some  cases  vesicles  do  not  ap- 
pear until  the  tenth  day  and  are  converted  into  pustules 
three  or  four  days  later.  The  further  progress  of  the  disease 
is  as  in  younger  individuals,  the  whole  course,  however,  being 
slower. 

The  disease  is  extremely  fatal  in  the  aged,  the  confluent  and 
the  hemorrhagic  forms  being  invariably  so.  Many  cases  die 
during  the  period  of  invasion,  while  others  succumb  as  soon  as 
the  stage  of  suppuration  is  reached.  The  complications  include 
meningitis,  pneumonia  or  bronchopneumonia,  pleurisy,  gan- 
grene, bedsores,  various  forms  of  mucous  inflammation,  pul- 
monary edema,  etc.  The  prodromal  stage  and  the  initial  stage 
of  variola,  before  the  appearance  of  the  eruption,  is  like  the  pro- 
dromal and  initial  stages  of  other  acute  infectious  diseases  and 
it  is  often  impossible  to  differentiate  between  them.  Some 
presumptive  diagnostic  points  have  been  given,  but  until  the 
appearance  of  the  macules — which  generally  first  show  upon  the 
forehead  and  wrists — a  positive  diagnosis  is  impossible.  After 
their  appearance  there  ought  to  be  no  further  doubt,  as  the 
only  disease  giving  a  similar  history  of  invasion  and  a  similar 
rash  being  measles.  This  is  readily  differentiated  by  the  milder 
symptoms,  catarrhal  and  conjunctival  inflammation,  the  more 
profuse  rash  and  absence  of  lumbar  pain,  etc.  In  variola 
there  is  a  sudden  drop  in  the  temperature  as  soon  as  the  erup- 


392 


PATHOLOGICAL    OLD    AGE 


tion  appears,  while  in  all  other  exanthemata  the  appearance  of 
the  eruption  is  marked  by  a  slight  rise  in  temperature. 

Treatment  of  smallpox  is  symptomatic  and  hygienic. 
There  is  no  specific  treatment  and  all  that  can  be  done  is  to 
treat  symptoms,  minimize  the  causes  of  complications  and  main- 
tain the  strength  of  the  individual.  The  distressing  or  danger- 
ous symptoms  are  the  fever,  cerebral  symptoms  (headache, 
delirium,  coma),  circulatory  disturbance,  pain,  pruritus  and 
exhaustion. 

The  fever  can  sometimes  be  controlled  by  antipyretics, 
especially  acetphenetidin  and  others  of  the  coal-tar  products, 
but  these  are  cardiac  depressants  and  must  therefore  be  com- 
bined with  ammonia  carbonate.  The  usual  combination  with 
caffein  is  irrational,  as  the  caffein  is  a  slow-acting  heart  stimu- 
lant, while  the  depressants  act  rapidly.  Quinine  is  a  safe  anti- 
pyretic in  all  infectious  diseases,  but  it  is  slow  in  action.  The 
delirium  should  be  controlled  by  the  use  of  bromides  and,  if 
these  fail,  codein  or  morphine  must  be  used.  If  the  heart 
becomes  weak,  we  must  use  cardiac  stimulants,  preferably 
caffein  or  camphor,  leaving  the  more  powerful  stimulants, 
like  strychnine,  ether,  strophanthus,  etc.,  for  emergencies. 
Nothing  will  take  the  place  of  cocaine  as  a  local  application  for 
the  intolerable  itching  that  sometimes  accompanies  the  erup- 
tion. For  exhaustion  we  should  proceed  as  in  typhoid  fever 
allowing,  however,  greater  leeway  in  the  selection  of  food.  The 
hygienic  and  prophylactic  measures  are  as  in  typhoid  fever. 

Varioloid  occurs  during  an  epidemic  in  persons  who  have 
been  vaccinated.  It  is  virtually  a  mild  variola  and  as  such 
can  attack  the  aged  as  well  as  younger  persons.  The  course 
of  the  disease  is  mild,  the  surface  lesions  rarely  proceeding  to 
the  vesicular  stage.  The  cerebral  symptoms  and  exhaustion 
are,  nevertheless,  severe  in  the  aged  and  may  cause  death. 
The  treatment  is  similar  to  that  of  the  graver  disease. 

Typhoid  fever  is  infrequent  in  the  aged.  When  it  does 
occur  its  early  manifestations  resemble  the  early  symptoms  of 
pneumonia  and  it  is  often  impossible  to  differentiate  them 
without  the  Widal  reaction  or  blood  test.  It  generally  begins 
after  a  prolonged  prodromal  malaise  with  slight  chills,  irregular 
fever  and  rapid  prostration.  The  classical  symptoms  and 
course  are  rarely  found  in   the   senile   cases.     Instead   of   the 


TYPHOID  FEVER 


393 


typical  temperature  curve  there  is  usually  an  irregular  tem- 
perature, sometimes  remittent,  sometimes  intermittent,  seldom 
going  above  1030,  more  often  remaining  in  the  neighborhood  of 
1020;  Instead  of  the  usual  progressive  rise  in  temperature 
and  increasing  severity  of  symptoms  for  a  week,  followed  by  a 
week  of  maximum  intensity  of  symptoms  with  a  steady  decline 
during  the  next  week,  the  disease  in  the  old  runs  an  irregular 
protracted  course  lasting  four  or  five  weeks.  The  period  of 
maximum  intensity  is  about  the  end  of  the  second  week.  The 
pulse  shows  some  peculiarities,  being  often  dicrotic,  and,  while 
in  younger  cases  the  rate  is  comparatively  low,  even  when  the 
fever  is  high,  in  senile  cases  it  is  generally  high  and  may  reach 
120  or  more  with  a  temperature  of  1020,  and  slight  causes, 
such  as  a  change  of  position,  will  cause  a  rapid  rise  of  20  or  30 
beats  per  minute  which  drops  again  a  minute  or  two  later. 
The  eruption  is  usually  lighter  in  color,  smaller,  and  scattered, 
and  may  escape  detection  altogether.  Instead  of  appearing 
in  successive  crops  the  first  crop  appears  at  the  end  of  the 
first  week  and  may  disappear  in  a  few  days  or  may  persist 
throughout  the  disease.  The  abdominal  symptoms  frequently 
differ  markedly  from  the  classical  symptoms  as  they  appear 
in  younger  individuals.  The  spleen  shows  no  enlargement. 
There  is  a  progressively  increasing  tympanites  which  may  set 
in  during  the  first  few  days  of  the  disease  and  which  is  more 
pronounced  than  in  maturity;  constipation  is  the  rule,  and 
the  typical  "peasoup"  diarrhea  is  infrequent.  There  is  some 
pain  in  the  ileocecal  region  and  occasionally  in  other  localities 
about  the  abdomen.  There  are  usually  sordes  about  the  teeth 
and  tongue  and  the  latter  is  dry,  brown,  often  cracked.  In 
severe  cases  there  is  extreme  mental  and  physical  depression, 
the  patient  is  semicomatose  or  there  is  a  low  muttering  delirium, 
the  respiration  is  shallow,  heart  weak  and  rapid,  and  the  whole 
appearance  that  of  the  prostration  preceding  death.  In  some 
cases  there  is  a  tremor  of  the  hands,  more  often  there  is  an 
unconscious  picking  at  the  bed-clothes,  and  twitching  of  the 
tendons,  or  else  there  is  a  complete  relaxation  of  the  limbs  as  in 
motor  paralysis.  The  gravity  of  the  symptoms  increases  until 
the  end  of  the  second  week.  Most  senile  typhoid  fever  cases 
succumb  at  this  time,  the  prostration  leading  to  collapse  and 
death.     In  the  cases  that  survive  this  period,  there  is  a  gradual 


394  PATHOLOGICAL   OLD   AGE 

improvement,  first  seen  in  the  cerebral  symptoms.  There  is 
also  a  clearing  of  the  tongue,  a  conscious  effort  to  swallow,  and 
the  patient  begins  to  sleep  naturally.  Later  appetite  returns 
and  with  it  increasing  strength.  Constipation  alternates  with 
diarrhea,  the  meteorism  disappears,  the  spots  fade,  and  the 
patient  is  free  from  pain.  Convalescence  is  slow  and  in  most 
cases  the  complications  that  have  occurred  during  the  progress 
of  the  disease  retard  complete  recovery  for  weeks  or  months 
after  the  disappearance  of  the  disease.  The  most  frequent 
complications  are  pulmonary  edema  following  hypostatic  con- 
gestion, bedsores,  intestinal  hemorrhage,  cardiac  exhaustion, 
bronchitis,  pneumonia  and  perforation.  Pulmonary  edema 
and  perforation  are  rapidly  fatal.  Intestinal  hemorrhage  is 
almost  always  fatal,  as  the  aged  individual  cannot  stand  the 
loss  of  blood,  and  dies  of  exhaustion.  Cardiac  exhaustion  can 
sometimes  be  overcome  by  the  use  of  rapidly  acting  cardiac 
stimulants.  A  complicating  pneumonia  is  generally  fatal,  either 
through  the  toxemia  itself,  or  through  pulmonary  edema. 
The  bronchitis  that  occurs  in  typhoid  fever  is  usually  purulent, 
which  may  lead  to  pulmonary  abscess  or  gangrene  or  to  a  cap- 
illary bronchitis.  There  is  occasionally  an  acute  nephritis, 
and  various  ulcerative,  hemorrhagic  and  degenerative  condi- 
tions may  result  from  the  typhoid  infection. 

The  diagnosis  of  typhoid  fever  in  the  aged  is  sometimes 
difficult  unless  the  bacilli  are  found,  or  the  Widal  test  is  made. 
The  clinical  manifestations  are  often  misleading,  owing  to  the 
irregular  course  of  the  disease ;  lower  temperature,  light  eruption, 
absence  of  splenic  enlargement  and  frequent  absence  of  the 
"peasoup"  diarrhea.  Mononuclear  leucopenia  exists  in  ty- 
phoid fever  unless  complicated  by  a  disease  in  which  leucocy- 
tosis  occurs.  Other  diseases  in  which  a  leucopenia  occurs 
are  readily  differentiated  from  typoid  fever  or  do  not  occur  in 
the  aged.  These  diseases  are  measles,  German  measles,  small- 
pox, mumps,  malaria,  tuberculosis,  influenza,  leukemia  and 
pseudoleukemia.  The  leucocyte  count  is  of  importance,  as 
it  enables  one  to  distinguish  an  early  stage  of  typhoid  fever 
from  sepsis,  pneumonia,  appendicitis  and  meningitis. 

The  early  clinical  manifestations  of  typhoid  may  simulate 
pneumonia,  sepsis  or  meningitis.  The  prostration  seen  in 
typhoid    may    be    seen    in    pneumonia    or    any    other    acute 


TYPHOID  FEVER  395 

grave  disease.  In  the  serous  inflammations — peritonitis  and 
pleurisy — the  mind  is  clear,  in  meningitis  there  is  intense  head- 
ache, photophobia,  tinnitus,  rapid  prostration,  and  the  mind  is 
dull,  unless  there  is  delirium,  when  it  is  active.  There  is 
besides  generally  a  history  pointing  to  cerebral  disease,  while 
abdominal  symptoms  that  are  always  found  in  typhoid  fever 
are  absent.  The  onset  of  pneumonia  resembles  the  onset  of 
typhoid  fever.  In  the  absence  of  a  Widal  test  the  early  diagno- 
sis based  upon  symptoms  and  physical  signs  must  be  deter- 
mined by  the  presence  or  absence  of  the  symptoms  and  signs 
of  pneumonia.  The  cerebral  symptoms  are  more  pronounced 
in  typhoid,  and  cough  if  not  present  at  the  onset  of  the  disease 
does  not  appear  during  the  first  week,  while  in  pneumonia  it 
appears  within  the  first  forty-eight  hours.  After  the  second 
day  the  physical  signs  in  most  cases  of  pneumonia  are  suffi- 
ciently pronounced  to  determine  the  diagnosis.  Other  diseases 
occurring  in  the  aged  which  begin  with  prostration,  chills,  fever 
and  a  profound  malaise  are  sepsis,  influenza  and  tuberculosis. 
The  invasion  of  miliary  tuberculosis  is  slow  and  never  as 
severe  as  typhoid.  The  early  bronchial  symptoms  of  influenza 
do  not  appear  in  typhoid  until  the  end  of  the  first  week;  the 
tongue  is  red  and  moist,  in  influenza  the  skin  is  reddened,  there 
is  often  a  herpetic  eruption  and  generally  a  copious  purulent 
or  mucopurulent  expectoration.  The  early  differential  diagnosis 
between  sepsis  and  typhoid  in  the  aged  is  often  difficult  and 
even  if  the  eruption  appears  it  is  not  always  a  certain  pathog- 
nomonic sign  as  roseate  macules  are  occasionally  observed  in 
sepsis  and  the  beginning  of  typhus.  The  diagnosis  of  sepsis 
is  often  based  upon  the  presumptive  signs  of  a  pronounced  initial 
chill,  pains  in  the  bones,  herpes,  hemorrhagic  macules,  rapid 
pulse  and  respiration,  while  rapid  profound  prostration  with 
cerebral  symptoms,  roseate  papules,  and  eventual  intestinal 
hemorrhage  point  to  typhoid.  Any  of  these  presumptive  symp- 
toms and  signs  may  occur  in  either  disease  and  we  must  often 
make  a  diagnosis  by  the  prominence  and  number  of  symptoms 
found  most  frequently  in  either  disease.  In  some  cases  a 
positive  diagnosis  cannot  be  made  without  examination  of 
blood,  urine  and  feces.  Typhoid  may  also  be  mistaken  for 
paratyphoid,  typhus  or  epidemic  cerebrospinal  meningitis. 
The  last  two  are  very  rare  in  the  aged,  appear  only  in  an  epi- 


396  PATHOLOGICAL   OLD    AGE 

demic  form,  and  proceed  to  a  very  grave  condition  within 
forty-eight  hours.  Cerebrospinal  meningitis  presents  a  pathog- 
nomonic pain  along  the  spine  with  stiffness  of  the  muscles  of 
the  neck.  Typhus  begins  with  a  chill,  there  is  high  fever, 
rapid  and  profound  prostration  and  the  eruption  is  scattered 
over  the  trunk  and  not  confined  to  the  abdomen.  The  eruption 
consists  of  rose-colored  macules  with  hemorrhagic  centers. 
In  paratyphoid,  which  is  a  rare  disease,  there  is  an  initial  chill, 
the  cerebral  symptoms  are  milder,  while  the  intestinal  symptoms 
are  more  pronounced.  There  is  usually  early  vomiting  and 
diarrhea,  frequently  herpetic  eruptions,  irregular  temperature 
and  the  whole  course  of  the  disease  is  milder. 

The  prognosis  of  typhoid  fever  in  the  aged  is  always  grave, 
even  in  cases  where  the  symptoms  are  mild.  The  chief  sources 
of  danger  are  the  prostration  leading  to  collapse,  pulmonary 
edema  following  hypostatic  congestion,  intestinal  hemorrhage 
and  perforation,  and  pulmonary  and  renal  complications. 
Protracted  cases  produce  general  exhaustion  and  a  relapse  is 
almost  always  fatal.  Many  deaths  are  due  to  complications 
other  than  pulmonary  and  renal  involvement. 

Treatment.  -There  is  no  positive  method  of  aborting,  short- 
ening or  curing  typhoid  fever,  the  typhoid  vaccines  being  still 
experimental,  and  therapeutic  measures  must  be  directed 
toward  amelioration  of  symptoms  and  prevention  of  complica- 
tions. The  most  important  of  the  therapeutic  measures  in 
maturity  is  hydrotherapy  applied  in  the  form  of  cold  baths 
given  according  to  the  Brand  or  Baruch  method.  In  senile 
cases  a  cold  bath  is  an  extremely  dangerous  experiment.  The 
shock  may  produce  collapse,  while  if  the  temperature  of  the 
bath  has  been  gradually  lowered,  there  may  be  no  reaction  in 
spite  of  friction,  hot  water  bottles,  hot  stimulating  drinks,  etc. 

If  the  rectal  temperature  is  1030  or  above,  cold  sponging  may 
be  tried,  but  if  the  first  application  of  cold  water  (never  ice  in  the 
aged)  produces  a  shock  it  must  be  discontinued  or  tepid  water 
substituted.  The  sponging  can  be  repeated  every  two  or  three 
hours,  but  the  patient  must  be  moved  as  little  as  possible,  and 
abdominal  manipulation  must  be  avoided.  The  usual  practice 
of  beginning  the  treatment  of  typhoid  fever  by  giving  repeated 
small  doses  of  calomel  can  serve  no  other  useful  purpose  than 
to  produce  catharsis.     It  has  no  influence  upon  the  disease. 


TYPHOID  FEVER  397 

If  there  has  been  constipation  a  single  dose  of  castor  oil  to  which 
5  grains  of  salol,  betanaphthol,  or  soda  sulphocarbolate  and  2 
grains  of  the  bile  salts  have  been  added,  will  act  better  than 
calomel.  If  there  is  diarrhea  a  powder  containing  dionin  1/6 
grain,  salol  5  grains  and  bismuth  sub  nitrate  10  grains  should 
be  given,  and  repeated  if  necessary  in  three  or  four  hours. 
Salol  and  the  sulphocarbolates  (Waugh  Abbott  formula) 
can  be  used  as  intestinal  antiseptics  throughout  the  disease. 
In  hyperpyrexia  quinine  will  give  the  most  permanent  re- 
sults, but  if  quick  action  is  necessary,  as  in  delirium  due  to 
high  temperature,  we  must  fall  back  upon  the  coal-tar  prepara- 
tions, preferably  acetphenetidin  or  antipyrin.  A  temperature 
of  1040  or  more  in  an  aged  patient  generally  points  to  a  compli- 
cating infection.  If  the  usual  antipyretics  do  not  reduce  the 
temperature  and  there  are  pronounced  cerebral  symptoms,  it 
may  be  necessary  to  resort  to  the  cold  bath  notwithstanding 
the  danger  of  shock  and  collapse.  The  bath  should  be  followed 
by  friction  and  hot  water  bottles  to  the  feet.  For  insomnia, 
urethane,  veronal,  sulphonal  or  trional  can  be  used,  and  opium 
only  if  the  other  remedies  fail  to  produce  sleep.  The  carbamate 
group  is  rather  safer  and  more  reliable  than  the  methane  group. 
It  is  of  the  utmost  importance  to  maintain  the  strength  of  the 
patient.  This  is  accomplished  partly  by  appropriate  diet  and 
partly  by  drugs.  The  drugs  to  be  used  for  this  purpose  are 
small  doses  of  strychnine,  caffeine  and  carbonate  of  ammonia. 
Digitalis  is  always  dangerous  and  strophanthus  should  be 
used  only  if  the  heart  becomes  weak  and  rapid.  In  a  weak 
and  slow  heart  spartein  should  be  used  in  1/2 -grain  doses 
every  three  hours  until  there  is  response.  Exhaustion  of  the 
heart  is  a  constant  danger  and  requires  prompt  treatment. 
When  this  sets  in  we  must  resort  to  hypodermic  injections  of 
strychnine,  ether  and  camphor,  and  give  internally,  brandy 
and  hot  coffee.  The  head  should  be  lowered  and  hot  water 
bottles  placed  to  the  feet. 

The  position  of  the  patient  should  be  occasionally  changed 
to  prevent  hypostatic  congestion.  It  is  impossible  to  guard 
against  intestinal  hemorrhage  or  perforation,  which  sometimes 
occur  in  spite  of  every  precaution.  Absolute  rest,  giving 
the  patient  an  opiate  if  necessary,  is  the  only  safe  measure  that 
can  be  suggested.     Subcutaneous  injections  of  a   2   per  cent. 


398  PATHOLOGICAL   OLD   AGE 

solution  of  gelatin  have  been  tried  in  hemorrhage  and  success 
is  reported.  Ergot  and  adrenalin  are  extremely  dangerous 
in  the  aged  on  account  of  their  vasoconstrictor  effect  upon  the 
whole  circulatory  apparatus,  nevertheless,  if  the  bleeding  con- 
tinues, a  hypodermic  injection  of  2  grains  of  ergotin  and  1 
grain  of  stypticin  can  be  tried.  High  enemata  of  starch, 
gelatin  and  hemostatics  have  been  suggested.  When  we 
remember  that  it  is  virtually  impossible  to  get  the  clyster  past 
the  ileocecal  valve  and  that  the  hemorrhage  almost  always 
comes  from  a  typhoid  ulcer  in  the  ileum  the  uselessness  of 
attempting  local  medication  by  way  of  the  rectum  must  be 
apparent.  A  more  rational  treatment  of  intestinal  hemorrhage 
would  be  by  means  of  the  metallic  astringents,  zinc  or  copper 
sulphate  given  by  mouth,  but  while  the  hemorrhage  may  be 
controlled,  the  danger  is  from  shock  and  exhaustion  which 
may  follow  the  loss  of  even  a  very  slight  quantity  of  blood. 
There  is  also  a  danger  from  the  irritation  of  these  salts  upon  the 
ulcers.  There  is  no  known  method  of  combating  perforation. 
Abdominal  section  has  been  recommended  but  no  cure  has  been 
recorded.  Other  complications  require  the  ordinary  treatment 
for  such.  Bedsores  can  be  avoided  if  the  skin  is  kept  dry  and 
the  pressure  points  are  protected.  The  care  of  the  typhoid 
fever  patient  is  more  important  than  drug  treatment  and  the 
diet  alone  may  change  the  entire  aspect  of  the  disease.  In  the 
selection  of  food,  two  factors  must  be  considered,  to  maintain 
strength  and  to  prevent  irritating  matter  from  reaching  the 
intestinal  lesions.  The  latter  factor  presents  peculiar  difficulties 
as  it  is  hardly  possible  to  arrange  a  dietary  which  will  not 
contain  refuse  matter,  or  matter  liable  to  undergo  fermentation 
or  decomposition  in  the  bowel.  The  safest  food  is  fresh  milk, 
but  the  amount  necessary  to  support  the  strength  of  an  aged 
person,  three  to  four  pints  daily,  imposes  excessive  work  upon 
the  circulatory  system.  To  avoid  the  excessive  quantity  of 
fluid,  the  condensed  or  evaporated  milk  should  be  used.  If 
the  milk  diet  becomes  objectionable,  its  taste  can  be  masked 
by  the  addition  of  salt,  coffee  or  chocolate,  or  one  of  the  prepared 
foods  may  be  substituted  temporarily  or  added.  The  foods 
containing  a  large  percentage  of  alcohol  should  be  avoided  and 
likewise  foods  consisting  principally  of  unconverted  starch 
and  those  containing  a  large  amount  of  lime.     During  the  first 


TYPHOID  FEVER  399 

week,  while  assimilation  is  good,  we  can  use  concentrated  foods, 
etc.  After  the  first  week,  or  if  assimilation  is  poor  and  undigested 
food  particles  appear  in  the  feces,  the  food  should  be  partially 
converted  or  predigested.  The  present-day  tendency  is  to 
permit  greater  latitude  in  the  variety  of  foods,  but  if  the  pre- 
viously recommended  food  substances  can  be  taken,  there  will 
be  less  danger  of  intestinal  irritation.  There  are  numerous 
simple  articles  of  food,  such  as  thin  barley  gruel,  albumin 
water,  malt  extract  and  gelatin,  which  are  unobjectionable 
and  which  may  be  occasionally  given,  but  they  contain  com- 
paratively little  nutritive  value.  When  there  is  extreme 
exhaustion  and  distaste  for  food,  only  the  most  concentrated 
foods  should  be  used.  Coffee  may  be  given  throughout  the 
disease.  Solid  food  should  not  be  permitted  until  at  least 
ten  days  after  the  temperature  has  become  normal.  Other 
hygienic  measures,  as  fresh  air,  sunshine,  rest,  quiet,  the  avoid- 
ance of  motion  except  the  occasional  shifting  from  side  to  side 
to  prevent  hypostatic  congestion,  are  self-evident.  The  patient 
should  not  be  permitted  to  exert  himself,  to  arise,  move,  turn, 
talk  much,  etc.  A  bed  pan  which  will  slide  easily  under  the 
body,  must  be  used. 

The  mouth,  tongue,  teeth  and  lips  should  be  regularly 
cleansed  with  an  alkaline  antiseptic  solution,  preferably  one 
containing  formaldehyde,  or  one  of  a  solution  of  peroxide  of 
hydrogen  or  permanganate  of  potash.  It  is  almost  unnecessary 
to  caution  the  attendants  about  the  thorough  disinfection  of  the 
discharges,  fecal,  urinary  and  salivary,  the  bed  pan  and  cuspidor, 
the  clothing  and  bedding  and  everything  that  had  been  used 
about  the  patient.  The  physician  himself  is  frequently  the 
carrier  of  the  infection  and  this  he  can  avoid  only  if  he  will  change 
his  clothes  before  seeing  the  next  patient  and  disinfect  the 
exposed  ones.  The  recently  introduced  antityphoid  serum  is 
apparently  a  reliable  prophylactic. 

Paratyphoid  fever  presents  apparently  no  marked  differ- 
ences between  that  of  maturity  and  that  of  senility.  The  few 
cases  reported  give  symptoms  resembling  a  mild  typhoid  and 
in  most  cases  bacteriological  or  Widal  reaction  tests  are  required 
to  determine  the  diagnosis.  The  disease  is  treated  as  is  typhoid 
fever. 

Typhus  fever  is  relatively  more  frequent  and  more  fatal  in 


400  PATHOLOGICAL    OLD    AGE 

the  aged  than  in  maturity.     It  is,  however,  rarely  met  with  in 
the  United  States  and  then  almost  exclusively  in  recent  immi- 
grants coming  from  countries  in  which  it  is  endemic.     In  the 
aged  the  period  of  incubation  is  prolonged,  the  disease  develops 
slowly  and  the  characteristic  eruption  may  not  appear  until 
the  tenth  day  or  later.     There  is,  however,  the  sudden  onset 
with  a  pronounced  chill  followed  by  a  fever  which  may  reach 
1040  on  the  third  or  fourth  day.     The  temperature  is  irregular, 
remittent,  or  continuously  high.     The  pulse  is  rapid  and  weak. 
Cerebral  disturbances  occur  early  and  delirium,  with  subsultus 
tendinum  and  coma,  may  appear  during  the  first  week.     The 
initial  eruption  of  red  macules  soon  shows  a  dark  hemorrhagic 
center.     In  some  cases  the  eruption  begins  with  petechiae,  in 
others  the  macules  almost  immediately  become  hemorrhagic. 
These  are  rapidly  fatal  cases.     There  is  extreme  prostration 
from  the  onset  of  the  disease  and  the  functional  activity  of  all 
the  organs  is  impaired.     Sordes  and  other  typhoid  symptoms 
appear  earlier  and  are  graver  than  in  typhoid  fever  and   the 
same  complications  that  may  occur  in  typhoid  may  also  occur 
in  typhus.     Hypostatic  congestion  is  one  of  the  most  frequent 
ones    and   is  fatal.     The   early   diagnosis   of    typhus   fever  is 
difficult,  as  typhoid  fever,   cerebrospinal  meningitis,  relapsing 
fever,  smallpox,  measles,  sepsis  and  pneumonia  may  all  begin 
with  a  chill,  high  fever  and  prostration,  following  a  period  of 
malaise.     Relapsing  fever  can  be  excluded  from  consideration 
as  it  does  not  occur  in  the  United  States  and  has  a  specific 
spirocheta  in  the  blood  which  is  recognizable  from  the  onset  of 
the  disease.     Measles  presents  neither  the  distinct  chill,  high 
fever  nor  prostration  of  typhus.     The  pain  and  contractions 
of  the  spinal  muscles  occurring  in  cerebrospinal  meningitis  are 
absent  in  typhus.     In  variola  the  eruption  begins  as  discrete 
papules  on  the  forehead  and  wrists  and  there  is  a  fall  in  the 
temperature  and  clearing  of  the  mind  as  soon  as  they  appear. 
Before  the  appearance  of  the  eruption  there  is  no  diagnostic 
sign  by  which  the  two  can  be  differentiated  although  the  prostra- 
tion is  not  so  severe  in  smallpox  nor  is  the  mind  dulled.       In 
hemorrhagic    variola   the   initial   symptoms   may   be   fully   as 
severe  as  in  typhus,  but  the  eruption  is  vesicular  and  there  is 
also  an  eruption  upon  the  fauces.     In  pneumonia  the  cough  and 
physical  signs  may  be  detected  on  the  second  day.     The  pres- 


INFLUENZA  4OI 

ence  of  the  pneumococci  will  establish  the  diagnosis.  Typhoid 
fever  may  give  the  same  severe  initial  symptoms  as  typhus,  or 
the  latter  disease  may  give  mild  initial  symptoms.  In  either 
case  no  definite  diagnosis  can  be  made  until  the  appearance  of 
the  rash,  which  in  typhus  may  be  seen  on  the  fourth  or  fifth 
day,  though  in  the  aged  it  appears  later,  and  the  bacteriological 
finding  of  the  typhoid  bacillus.  In  sepsis  an  early  diagnosis 
can  usually  be  made  by  the  presence  of  the  pyogenic  germs. 
In  most  contagious  diseases  the  existence  of  an  epidemic  sim- 
plifies the  diagnosis. 

Treatment  is  purely  symptomatic  and  demands,  primarily, 
the  support  of  the  patient's  strength.  There  being  no  specific 
intestinal  lesions  as  in  typhoid  fever,  greater  latitude  is  permitted 
in  the  selection  of  food,  which  should  be  as  concentrated  as 
possible,  and  any  indication  of  intestinal  disorder,  as  evidenced 
by  sour  or  foul-smelling  stools,  or  the  presence  of  particles  of 
undigested  food,  should  be  met  by  a  thorough  catharsis,  fol- 
lowed by  an  intestinal  antiseptic,  and  a  milk  or  predigested  food 
diet.     The  medicinal  treatment  is  the  same  as  in  typhoid  fever. 

Influenza  occurs  rather  frequently,  the  advantage  of  greater 
resistance  being  more  than  counterbalanced  by  the  presence  of 
chronic  bronchitis,  the  impaired  mucous  membrane  forming  a 
fertile  field  for  the  propagation  of  the  pathogenic  bacilli.  The 
disease  in  the  aged  is  usually  of  a  toxemic  respiratory  type, 
rarely  the  nervous  form,  still  more  rarely  the  gastrointestinal 
type.  There  are  rarely  typical  cases  of  any  of  these  forms  of 
the  disease,  most  cases  presenting  symptoms  of  all  types,  the 
toxemic  and  respiratory  symptoms  predominating.  There  are 
no  marked  differences  in  the  symptoms  between  maturity  and 
senility.  The  temperature  is  usually  low,  rarely  over  1020, 
frequently  it  ranges  between  normal  and  ioo°.  Owing  to  the 
atrophy  of  the  nasal  mucous  membrane  the  rhinitis  may  be 
absent  but  conjunctivitis  may  be  marked.  The  disease  begins 
with  the  usual  mild  chills  followed  by  elevation  of  temperature, 
headache,  pains  in  the  extremities  and  back.  A  pharyngitis 
is  noted,  followed  by  a  laryngitis,  the  catarrhal  inflammation 
proceeding  downward  into  the  trachea  and  bronchi.  Facial 
herpes  occurs  frequently  and  the  face  is  usually  flushed,  some- 
times in  patches.  The  disease  itself  is  not  grave,  but  the 
frequency  of  pulmonary  complications,  especially  lobular  pneu- 
26 


402 


PATHOLOGICAL   OLD   AGE 


monia  and  pleurisy,  makes  it  one  of  the  more  serious  diseases  of 
old  age.  Owing  to  the  mildness  of  the  initial  symptoms  of  the 
bronchopneumonia,  that  complication  is  frequently  overlooked 
until  near  the  fatal  end.  (See  Senile  Pneumonia.)  The  earliest 
symptom  of  bronchopneumonia  is  usually  an  irregular  rise  and 
fall  of  the  temperature,  but  this  may  not  be  noticed  unless  the 
temperature  is  taken  every  two  hours  after  the  first  rise  is  noted. 
Circulatory  disturbances,  evidenced  by  weak  cardiac  impulse, 
weak  pulse,  arrhythmia,  dyspnea  and  cyanosis,  occur  frequently, 
especially  during  the  period  of  convalescence.  Cerebral  and 
nervous  complications  are  infrequent  with  the  exception  of 
trigeminal  neuralgia.  Some  cases  of  lobular  pneumonia  appear 
without  the  initial  coryza,  and  laryngitis,  and  the  diagnosis 
can  be  made  only  by  finding  the  influenza  bacillus,  and  cases 
have  been  reported  giving  cerebral  symptoms  alone  but  showing 
the  bacilli  in  the  cerebrospinal  fluid. 

A  positive  diagnosis  can  be  made  only  when  the  pathogenic 
germs  are  found.  In  the  absence  of  these  findings,  the  disease 
may  be  mistaken  for  a  simple  cold,  although  in  the  latter  attack 
the  acute  invasion,  prostration,  neuralgia  and  herpes  are  absent 
or  mild.  The  coryza,  and  early  bronchitis  will  distinguish  it 
from  meningitis,  tuberculosis  and  typhoid. 

Ortner  describes  under  the  name  chronic  influenza  a  type 
which  is  protracted  or  recurrent  and  where  the  bacilli  can  be 
found  for  a  long  period  in  the  sputum  and  nasal  secretion.  It 
occurs  in  aged  emphysematous  individuals,  either  following  an 
acute  attack,  or  coming  on  with  mild  symptoms  of  malaise  and 
coryza.  The  symptoms  may  persist  for  months  and  the  bacilli 
are  found  for  a  long  time  after  all  symptoms  have  disappeared. 

The  treatment  of  influenza  is  symptomatic  and  hygienic. 
French  physicians  use  colloidal  metals  by  inunction  or  by  sub- 
cutaneous or  intravenous  injection  as  curative  agents  in  infec- 
tious diseases  generally,  but  this  mode  of  treatment  is  still 
experimental.  For  the  relief  of  symptoms  the  measures  useful 
in  earlier  life  can  be  employed,  with  due  regard,  however,  for 
the  degenerated  state  of  the  tissues.  Antipyretics  are  rarely 
required.  For  the  neuralgia,  distressing  cough  without  expec- 
toration, or  with  scanty  tenaceous  mucus,  for  insomnia,  dyspnea, 
etc.,  the  same  treatment  is  required  as  in  simple  neuralgia, 
bronchitis,  cardiac  asthma,  etc. 


ACUTE  ENDOCARDITIS 


ACUTE  ENDOCARDITIS 


403 


Etiology. — Contrary  to  the  generally  accepted  view  that 
acute  endocarditis  is  probably  of  bacterial  origin  in  all  cases,  we 
find  that  but  few  cases  occurring  in  eld  age  follow  a  bacterial 
disease,  while  even  in  younger  life  endocarditis  has  been  found 
in  most  cases  of  fatal  chorea.  We  must  either  assume  that  such 
diseases  of  the  fourth  group  as  diabetes,  gout,  cancer  and 
chronic  nephritis  during  which  valvular  disease  frequently 
develops,  are  bacterial,  or  else  we  must  drop  the  assumption 
that  acute  endocarditis  is  always  of  bacterial  origin. 

Acute  endocarditis  is  due  to  inflammation  of  the  endocar- 
dium produced  by  some  irritating  constituent  of  the  blood. 
This  may  be  bacteria  or  bacterial  or  other  toxins,  or  else  the 
abnormal  constituents  found  in  the  blood  in  diabetes,  gout,  ne- 
phritis, etc.  The  bacterial  endocarditis  is  rare  in  the  aged  as 
bacterial  diseases  producing  endocarditis  are  infrequent  at  that 
time  of  life.  The  simple  non-bacterial  form  is  rarely  recognized, 
the  assumption  of  its  existence  being  usually  based  upon  the 
production  of  a  valvular  lesion  in  the  course  of  the  causative 
disease. 

Pathology. — In  the  bacterial  form  there  is  a  deposit  of 
fibrin  in  which  leucocytes  and  blood  plates  are  imbedded  upon 
the  valves  or  less  frequently  upon  the  cordas  tendinae  or  other 
parts  upon  which  the  blood  impinges.  This  is  followed  by  a 
proliferation  of  endothelium  and  subendothelial  connective 
tissue  into  this  deposit,  the  whole  forming  the  so-called  "vege- 
tations," fringes  or  warty  excrescences  from  1/30  to  1/4  inch 
in  thickness,  continuous  with  the  adjacent  tissue.  In  rare 
cases  the  vegetation  is  attached  to  the  base  by  a  pedicle.  These 
vegetations  interfere  with  the  free  action  of  the  valves,  some- 
times they  contract,  producing  marked  valvular  deformity. 
During  the  continuation  of  the  disease  the  vegetations  are 
covered  with  a  layer  of  fibrin  which  affords  a  lodgment  for 
pyogenic  bacteria  and  if  an  invasion  of  such  bacteria  takes 
place  the  disease  becomes  an  ulcerative  or  malignant  endo- 
carditis. In  this  case  the  vegetations  may  soften,  ulcerate  and 
suppurate,  necrosed  tissue  is  thrown  off  and  carried  in  the 
blood  current  as  emboli,  usually  plugging  some  vessel  in  the 
brain,  liver,  spleen,  kidneys  or  other  organ.     This  latter  con- 


404 


PATHOLOGICAL   OLD   AGE 


dition  is,  however,  extremely  rare  in  the  aged,  as  the  aged  in- 
variably succumb  within  a  few  days  after  the  septic  infection. 
Fragments  from  non-septic  vegetations  may  be  torn  off  and 
cause  emboli  and  infarctions  in  distant  parts. 

In  the  non-bacterial  endocarditis  there  is  a  thickening  of  the 
endothelium  with  deposit  of  fibrin,  but  no  organization  into 
vegetations.  The  action  of  the  valves  is,  however,  always  in- 
terfered with.  In  most  cases  occurring  in  the  aged  there  are 
at  the  same  time  senile  changes  in  the  endocardium  (see  Senile 
Endocarditis)  and  only  the  presence  of  the  fibrin  deposits 
distinguishes  the  acute  inflammatory  condition  from  the  non- 
inflammatory senile  degeneration. 

Symptoms. — In  the  non-bacterial  variety  of  acute  endocar- 
ditis, before  the  valvular  lesions  give  their  distinctive  symp- 
toms, the  only  symptom  that  might  attract  attention  is  irregu- 
lar heart  action.  Even  this  usually  escapes  notice  until  the 
valvular  murmur  appears.  When  the  irregular  heart  action 
is  so  marked  as  to  be  noticeable  it  is  usually  attributed  either 
to  the  causative  disease  or  else  to  the  senile  changes  in  the 
heart.  There  is  no  pain  or  elevation  of  temperature  connected 
with  this  variety  of  endocarditis. 

In  the  bacterial  variety  the  earliest  symptom  is  a  rise  in 
temperature  not  due  to  any  apparent  change  in  the  character  of 
the  causative  disease.  The  rise  may  be  two  or  three  degrees. 
About  the  same  time  the  heart  action  becomes  accelerated  and 
irregular,  there  is  a  feeling  of  discomfort  about  the  heart  and 
the  circulation  is  disturbed.  These  symptoms,  which  are 
usually  mild,  are  followed  by  symptoms  of  valvular  incom- 
petency, occasionally  stenosis,  the  mitral  valve  being  usually 
first  involved.  The  later  symptoms  are  those  of  the  valvular 
lesion.  In  the  malignant  or  ulcerative  form  of  acute  endocar- 
ditis there  is  a  sudden  rise  in  temperature  of  two  or  three  or 
more  degrees,  marked  mental  and  physical  depression,  sweating, 
irregular  heart  action  rapidly  followed  by  the  valvular  lesion 
and  its  symptoms.  In  the  aged  death  usually  occurs  in  a  few 
days  without  the  occurrence  of  embolism,  the  most  frequent 
complication  in  younger  individuals.  There  are  several  types 
of  this  variety  of  endocarditis,  typhoid,  septic,  meningeal  and 
a  type  in  which  the  cardiac  and  circulatory  disturbances  are 
most  prominent.     The  rare  cases  that  occur  in  the  aged  present 


Lung,  Chronic  Interstitial  Pneumonia,  Bronchiectasis, 
Hyaloserositis,  and  a  Terminal  Catarrhal  Pneumonia  Re- 
sulting from  Concurrent  Infection  by  the  Tubercle  Bacil- 
lus and  Pneumococcus.  (From  Coplin's  "Manual  of  Pathol- 
ogy.") A,  A.  Greatly  thickened  pleura.  B.  Dilated  bron- 
chi. C.  One  of  many  strata  of  fibrous  tissue  irregularly 
transversing  the  organ.  D.  Large  caseous  lymph-node  near 
hilum  of  lung,  and  immediately  adjacent  to  the  aorta,  a 
section  of  which  is  shown  just  above.  The  aorta  is  the 
seat  of  slight  atheroma. 


INFECTIOUS  PNEUMONIA  405 

typhoid  symptoms.  These  cases  are  invariably  fatal.  The 
non-malignant  forms  in  the  aged  become  chronic  and  follow 
the  course  of  senile  endocarditis. 

Treatment. — No  form  of  treatment  has  been  of  the  slightest 
avail  in  the  malignant  form  of  the  disease.  For  other  forms 
rest  is  of  the  utmost  importance.  Cloths  wrung  out  in  cold 
water  and  placed  over  the  heart  will  relieve  temporarily  the 
irregularity  and  the  feeling  of  discomfort  in  the  organ.  As 
long  as  the  underlying  cause  persists  the  irritation  and  inflam- 
mation will  persist  and  continue  to  do  irrepairable  damage. 
The  further  treatment  is  such  as  has  been  indicated  under 
senile  endocarditis  and  the  valvular  disease  that  had  been 
produced.  Various  drugs  have  been  recommended,  such  as  the 
iodides  to  promote  absorption  of  the  lymph,  mercury  in  various 
forms  to  prevent  the  deposit  of  fibrin,  alkalies  to  increase  the 
alkalinity  of  the  blood,  aconite  and  veratrum  to  weaken  the 
force  of  the  heart,  etc.  They  are  rarely  given  in  time  to  be 
effective. 

INFECTIOUS  PNEUMONIA 

It  has  already  been  stated  in  the  chapter  on  senile  pneu- 
monia that  faulty  nomenclature  and  other  causes  have  pro- 
duced confusion  in  the  conception  of  the  various  pathological 
states  included  under  the  term  "pneumonia."  In  this  work 
all  pulmonary  inflammations  are  divided  into  two  classes,  in- 
fectious and  non-infectious  pneumonias.  In  the  non-infectious 
class  are  placed  inflammations  due  to  irritation,  extension  of 
non-infectious  inflammations,  and  secondary  inflammations 
not  due  to  pathogenic  germs.  In  the  infectious  class  are  in- 
cluded those  inflammations  which  are  caused  by  pathogenic 
germs. 

Etiology. — The  most  frequent  cause  of  infectious  pneumonia 
is  activity  of  Frankel's  pneumococcus.  Other  germs  that  are 
known  to  cause  pulmonary  inflammation  are  the  Friedlander 
bacillus,  streptococcus,  staphylococcus,  micrococcus  catar- 
rhalis,  the  diphtheria,  influenza,  typhoid  and  colon  bacilli  and 
the  meningococcus.  It  is  believed  that  other  germs  are  also 
able  to  cause  the  disease,  as  it  occurs  occasionally  in  the  course 
of  measles,  whooping  cough,  typhus,  variola  and  other  presum- 


4q6  PATHOLOGICAL    OLD    AGE 

ably  germ  diseases.  The  senile  organism  is  more  resistant  to 
germ  activity  than  the  organism  in  earlier  life,  but  the  resisting 
power  may  be  lowered  through  general  debility.  In  most  cases  a 
fertile  field  is  prepared  by  a  previous  disease  or  by  a  momentary 
perversion,  as,  for  example,  when  inhaling  cold  air,  a  tempo- 
rary hyperemia  is  produced  in  order  to  raise  the  air  to  the  body 
temperature,  this  hyperemic  surface  becoming  a  suitable  field 
for  germ  development.  Local  traumas  leave  points  of  exposure 
for  the  entrance  of  the  pathogenic  germs,  while  the  shock  of 
traumas  generally  reduces  the  vitality  of  the  body  and  lowers 
its  resisting  power  to  germ  development.  The  irritation  pro- 
duced by  the  inhalation  of  dust  or  noxious  vapors  causes  local 
hyperemia,  or  a  catarrhal  condition  which  favors  the  bacterial 
activity  upon  which  the  disease  depends.  Passive  hyperemia, 
bronchitis,  pneumokoniosis,  and  interstitial  pneumonia,  all 
supply  suitable  fields  for  the  propagation  of  the  germs.  While 
the  germs  generally  reach  their  field  by  inhalation  they  may 
reach  their  localization  in  the  lungs  through  the  lymph  and 
blood  channels. 

A  pure  pneumococcus  infection  is  rare  in  old  age  and  there- 
fore a  classical  acute  lobar  pneumonia  is  infrequent.  It  is 
almost  always  a  mixed  infection  in  which  the  pneumococci  and 
streptococci  predominate.  In  many  cases  no  pneumococci  are 
found,  and  in  cases  where  pneumonia  occurs  as  a  complication  of 
another  infectious  disease  the  germs  of  the  primary  disease  pre- 
dominate, or  are  alone.     Most  cases  in  the  senile  are  secondary. 

Pathology. — The  classical  stages  of  acute  lobar  pneumonia 
are  rarely  found  in  the  aged.  The  disease  may  be  localized  or 
diffused.  Upon  section  during  consolidation,  the  surface  ap- 
pears dark  red,  smooth  and  moist,  exuding  a  bloody  serum. 
Gray  hepatization  is  very  rare,  the  patient  seldom  surviving  the 
stage  of  red  hepatization,  and  where  recovery  does  take  place, 
resolution  begins  during  this  stage.  In  diffused  pneumonia, 
hyperemic  areas  are  scattered  throughout  the  lungs,  frequently 
in  the  upper  lobes  or  in  the  upper  part  of  the  lower  lobes.  The 
microscopic  appearance  depends  mainly  upon  the  type  of  the 
predominating  germs.  In  cases  where  the  pneumococci  pre- 
dominate, the  alveoli  are  filled  with  a  fibrinous  exudate.  The 
influenza  bacilli  cause  greater  destruction  of  the  epithelial  cells, 
and  their  debris  may  completely  fill  the  alveoli.     If  pyogenic 


INFECTIOUS  PNEUMONIA  407 

germs  are  present,  pus  cells  will  be  found.  In  most  senile  cases 
the  alveoli  contain  principally  serum  and  broken-down  epithe- 
lial cells,  some  fibrin,  red  blood  cells,  leucocytes  and  occasion- 
ally pus  cells.  The  capillaries  are  swollen  and  engorged.  In- 
cidental pulmonary  lesions  such  as  caseous  degeneration  due  to 
tuberculosis,  abscess  and  gangrene  due  to  pyogenic  bacteria, 
interstitial  edema,  etc.,  are  found  occasionally. 

Symptoms. — The  usual  sudden  onset  of  acute  lobar  pneu- 
monia, with  a  chill  followed  by  high  fever,  is  infrequent  in  the 
aged.  When  this  does  occur  there  is  almost  always  a  profound 
pneumococcic  infection,  with  rapid  prostration,  and  a  fever 
ranging  from  1020  to  1040.  Within  a  day  or  two  there  is  a 
distressing  cough,  and  some  time  later  blood-streaked  expectora- 
tion appears.  The  sputum  is  scanty  and  tenaceous;  in  some 
cases,  however,  it  is  entirely  absent.  Many  senile  patients  will 
swallow  the  expectoration  unless  watched.  Pain  is  usually 
slight.  In  this  form  of  infectious  pneumonia  the  disease  is 
grave  from  the  onset,  and  prostration  is  rapid,  the  breathing  is 
shallow  and  rapid,  but  not  panting  as  in  younger  persons; 
dyspnea  is  not  marked,  but  cyanosis  sets  in  early  and  cerebral 
symptoms  are  pronounced.  The  heart  at  the  onset  acts  with 
increased  force  and  rapidity,  but  it  soon  becomes  weak  and  grows 
weaker  as  the  prostration  increases.  Delirium  sets  in  early. 
There  is  usually  constipation,  the  urine  is  diminished  and 
albuminous  and  may  contain  casts.  The  amount  of  urea  is 
diminished.  In  acute  lobar  pneumonia  in  the  aged,  death  may 
occur  during  the  first  or  second  day,  and  is  rarely  delayed 
beyond  the  eighth  day.  If  improvement  does  take  place  the 
fever  gradually  subsides,  the  expectoration  becomes  more  pro- 
fuse and  the  mind  becomes  brighter.  The  face,  which  has 
usually  a  dark  flush  over  the  malars,  resumes  its  normal  appear- 
ance. Recovery  is  by  lysis.  A  sudden  drop  in  temperature 
occurs  before  dissolution,  while  a  copious  watery  expectoration, 
with  increasing  dyspnea,  indicates  pulmonary  edema. 

In  most  cases  of  infectious  pneumonia  in  the  aged  the  dis- 
ease develops  rapidly  but  not  suddenly.  Where  it  occurs  sec- 
ondarily to  another  disease,  the  symptoms  of  the  primary  dis- 
ease are  aggravated,  there  is  besides  a  rapid  rise  in  temperature, 
dyspnea,  and  rapid  shallow  breathing,  followed  by  cough  and 
expectoration,  which  after  a  day  or  two  becomes  blood-streaked 


408  PATHOLOGICAL   OLD   AGE 

and  may  be  purulent.  In  some  cases  the  system  had  been  so 
weakened  that  the  patient  is  unable  to  cough  while  the  mind 
may  be  too  impaired  to  realize  the  import  of  the  local  irritation 
produced  by  the  secretion  in  the  vesicles  and  tubes.  In  such 
cases  cough  and  expectoration  will  be  absent,  but  the  increas- 
ing amount  of  secretion  will  lessen  the  aerating  surface,  the 
dyspnea  will  increase,  cyanosis  sets  in  and  the  respiration 
becomes  more  rapid.  In  every  case  of  pneumonia,  whether 
infectious  or  non-infectious,  primary  or  secondary,  localized 
or  diffused,  there  is  rapid  prostration,  loss  of  appetite  and 
mental  depression.  There  is  generally  some  pain  when  cough- 
ing or  when  taking  a  deep  inspiration.  If  the  disease  is  local- 
ized, the  pain  is  located  in  the  affected  part,  but  where  there 
are  scattered  areas  of  consolidation,  the  pain  on  inspiration  is 
most  severe  where  the  affected  part  of  the  lung  in  expanding 
rubs  against  the  pleura, — while  the  pain  on  coughing  is  most 
severe  in  those  areas  in  which  the  consolidation  has  been  most 
complete,  i.e.,  in  the  parts  first  involved.  There  may  also  be 
pleuritic  pain  on  coughing.  Pain  is  not  felt  when  cerebral 
symptoms  appear.  A  pneumonia  following  a  hemorrhagic 
infarct  of  the  lung  presents  a  blood-stained  watery  expectora- 
tion, but  this  condition  is  seldom  found  in  the  aged.  The 
physical  signs  depend  upon  the  type.  There  is  dulness  upon 
percussion  over  the  affected  site,  but  this  dulness  may  be  com- 
pletely masked  by  an  area  of  emphysema  over  the  consolida- 
tion. In  the  localized  type,  dulness  at  the  base  points  to  a 
hypostatic  pneumonia  which  may  be  infectious  or  non-infec- 
tious. The  usual  sites  of  a  localized  pneumonia  in  the  aged 
are  the  apex  or  base  of  the  upper  lobe,  the  apex  of  the  lower 
lobe  or  the  side  of  the  upper  or  middle  lobe.  The  dulness  is 
then  found  either  in  the  supraclavicular  space,  or  in  the  inter- 
scapular space,  or  below  the  axilla.  In  the  diffuse  type,  small 
areas  of  dulness  may  be  found  over  all  parts  of  the  lung.  An 
important  sign,  both  of  the  disease  and  its  locality,  is  that  of 
crepitation,  heard  at  the  end  of  inspiration  and  at  the  begin- 
ning of  expiration.  Owing  to  the  senile  anatomical  changes 
in  the  chest  wall,  we  do  not  find  any  difference  in  expansion  and 
owing  to  the  frequent  presence  of  an  old  bronchitis  rales  may 
be  heard  in  all  parts  of  the  chest. 

When  resolution  sets  in  the  symptoms  abate,  but  in  the 


INFECTIOUS  PNEUMONIA  409 

diffuse  type  new  foci  of  infection  may  occur,  while  old  areas 
of  consolidation  clear  up,  and  thus  we  may  get  an  irregular 
temperature  with  remissions  and  intermissions;  periods  of 
improvement  with  relapses,  and  with  changing  areas  of  infec- 
tion. The  pneumonia  may  be  then  prolonged  for  several  weeks, 
the  system  becoming  constantly  weaker  and  the  patient  finally 
succumbing  from  general  exhaustion,  cardiac  exhaustion  or 
pulmonary  edema.  During  the  initial  fever  the  heart  action 
is  more  powerful  than  normal,  but  it  rapidly  weakens,  partly 
as  a  reaction  from  the  excessive  activity,  partly  through  im- 
paired pulmonary  circulation  (the  right  heart  being  weakened 
and  dilated),  and  partly  through  the  toxemia  which  alters 
the  circulating  medium  and  interferes  with  the  vasomotor 
regulation.  These  circulatory  changes  cause  passive  conges- 
tion of  the  liver,  spleen  and  kidneys,  with  consequent  impairment 
of  their  functions.  The  urine  is  diminished  in  quantity,  the 
amount  of  urea  and  chlorides  is  lessened,  while  albumin,  casts, 
an  excess  of  uric  acid  and  red  and  white  blood  cells  are  usually 
present.  When  resolution  sets  in  the  urine  becomes  normal 
unless  a  nephritis  had  developed.  The  most  prominent  and 
most  serious  indication  of  hepatic  disturbance  is  icterus. 

The  blood  in  infections  pneumonia  shows  a  leucocytosis, 
with  increase  in  fibrin.  When  resolution  sets  in  a  proteolytic 
ferment  appears  in  the  blood.  Nervous  and  cerebral  symptoms 
usually  appear  early  such  as  headaches,  insomnia,  later  delirium 
and  finally  coma,  diminished  reflexes,  neuritis,  etc. 

Pneumonia  is  the  most  fatal  disease  of  the  aged.  This  is 
partly  due  to  the  fact  that  the  onset  is  usually  so  mild  that  the 
disease  is  far  advanced  before  it  is  recognized.  It  is  only  in  the 
forms  that  are  rare  in  old  age,  such  as  acute  lobar  pneumonia 
and  general  pneumococcic  infection  that  pronounced  symptoms 
appear  from  the  onset  of  the  disease,  and  these  forms  are 
usually  virulent  and  fatal.  It  is  the  most  frequent  of  all  com- 
plications and  the  hypostatic  form  is  a  constant  menace  in  every 
case  in  which  a  patient  is  confined  to  his  bed.  In  many  cases 
the  physical  signs  can  be  found  before  there  are  any  suggestive 
symptoms  and  it  is  therefore  necessary  frequently  to  percuss 
the  back  of  the  chest  in  order  to  determine  any  foci  of  dulness 
present.  In  some  cases,  where  the  only  suggestive  symptom  of 
pneumonia  is  rapid  prostration,  we  can  get  a  history  of  exposure 


4io 


PATHOLOGICAL   OLD   AGE 


which  may  show  the  inhalation  of  cold  or  ratified  air  or  of 
noxious  vapors;  or  the  patient  may  remember  that  a  bit  of 
food  went  "in  the  wrong  way,"  thereby  producing  a  deglutition 
pneumonia.  More  often  there  is  a  history  of  another  disease 
or  traumatism  and  the  examination  of  the  chest  will  explain  why 
the  symptoms  suddenly  became  aggravated.  Cases  may  re- 
cover when  seen  early,  but  where  pneumococci  predominate; 
or  if  the  disease  is  secondary  to  typhoid  fever,  death  is  almost 
inevitable.  While  the  prognosis  is  unfavorable  in  every  case 
of  pneumonia,  whether  infectious  or  non-infectious,  there  are 
cases  offering  a  fair  chance  for  recovery.  These  are  the  inhala- 
tion pneumonias  and  those  pneumonias  that  are  due  to  other 
germs  than  the  pneumococci.  Rapid  prostration  diminishes 
the  chances  for  recovery.  Purulent  or  mucopurulent  expectora- 
tion indicates  the  presence  of  pyogenic  germs  which  may  cause 
abscess  or  gangrene  of  the  lung.  The  only  diseases  that  may 
be  mistaken  for  pneumonia  are  pleurisy,  bronchitis,  tuberculosis 
and  typhoid  fever.  In  early  pleurisy  there  is  absence  of  per- 
cussion dulness,  and  of  rapid  shallow  respiration;  there  are 
friction  sounds,  but  no  rales.  In  pleurisy  with  effusion,  the 
change  in  the  level  of  percussion  dulness  upon  change  in  position 
will  distinguish  it  from  the  graver  disease.  In  bronchitis  there 
are  no  areas  of  dulness,  and  there  is  generally  a  history  of  previ- 
ous cough  and  expectoration,  the  expectoration  being  thinner 
and  more  profuse  than  that  of  pneumonia.  There  is  no  prostra- 
tion or  pain.  Tuberculosis  is  slow  in  its  progress  and  the 
sputum  contains  the  pathogenic  bacilli.  If  there  is  any  doubt 
about  the  differential  diagnosis,  it  can  be  cleared  up  by  the 
microscope  and  by  the  tuberculin  test.  The  differentiation 
between  typhoid  fever  and  pneumonia  depends  upon  the 
bacteriological  examination  of  the  sputum,  blood  and  feces, 
and  upon  the  Widal  test. 

Treatment. — The  treatment  of  infectious  pneumonia  follows, 
in  the  main,  the  lines  laid  down  for  the  treatment  of  senile 
pneumonia.  In  addition  to  these  measures,  which  are  intended 
to  relieve  symptoms  and  prevent  the  most  frequent  causes  of 
death,  serum  therapy  should  be  employed.  Infectious  pneu- 
monia in  the  aged  is  almost  always  a  mixed  infection  and  the 
antipneumococcic  serum  has  little  effect  upon  it.  Serum 
therapy  is  worse  than  useless  if  it  is  not  based  upon  a  bacterio- 


TUBERCULOSIS  411 

logical  examination.  In  all  cases  in  which  the  symptoms  may- 
be ascribed  to  two  or  more  forms  of  bacteria  it  is  necessary  to 
make  such  examinations  before  using  any  serum,  vaccine, 
bacterin  or  any  other  bacterial  product.  There  are  various 
combinations  of  sera  and  vaccines  on  the  market  and  the 
selection  of  the  appropriate  combination  depends  upon  the 
bacteriological  examination  of  the  expectoration,  or  of  the  blood. 
Wherever  possible,  an  autogenous  vaccine  should  be  used  in 
preference  to  stock  vaccines. 

Some  incidental  symptoms  may  occur  in  infectious  pneumonia 
that  do  not  occur  in  the  non-infectious  senile  form.  For  the 
fever  we  can  use  quinine  or  tepid  sponging,  never  the  coal-tar 
products  or  cold  baths.  Creosote  is  of  service  if  the  cough  is 
distressing.  The  pernicious  practice  of  giving  narcotics  is 
probably  responsible  for  many  deaths  in  pneumonia,  by  further 
weakening  the  respiratory  centers,  and  by  allaying  the  irritation 
caused  by  the  mucus,  which  is  so  necessary  to  arouse  the  reflex 
action  of  coughing  for  the  removal  of  the  secretion.  If  the 
expectoration  is  thin,  yet  the  patient  cannot  bring  it  up,  senega 
should  be  given,  but  if  there  is  a  scanty  tenaceous  expectora- 
tion, muriate  of  ammonia  should  be  employed. 

The  hygienic   measures   are  the  same   as  those   of   senile 
pneumonia. 


TUBERCULOSIS 

Tuberculosis  in  the  form  of  fibroid  phthisis  occurs  more 
frequently  in  old  age  than  in  earlier  life.  The  disease  is  rarely 
a  primary  infection  in  the  aged,  being  in  almost  every  case  a 
recrudescence  of  a  disease  that  had  been  apparently  arrested 
years  before.  It  is  possible  that  in  some  cases  the  infection 
has  occurred  at  a  time  when  the  body  was  able  to  resist  its 
pernicious  activity  and  that  in  the  course  of  years  the  resistance 
was  lowered  and  the  latent  bacilli  became  active,  or  that  late 
in  life  the  virulence  of  the  germs  had  increased.  The  acute  or 
general  tuberculosis  is  rare  in  advanced  life  and,  while  local 
infection  may  occur  almost  anywhere  just  as  in  younger  indi- 
viduals, the  usual  location  is  in  the  lungs  where  it  produces  a 
fibroid  degeneration. 


4I2  PATHOLOGICAL   OLD   AGE 

Fibroid  Phthisis 

This  is  the  usual  form  in  which  tuberculosis  appears  in  the 
aged.  The  disease  is  slowly  progressive  and  may  exist  for 
years  before  the  symptoms  are  sufficiently  severe  to  cause  the 
patient  to  seek  medical  aid,  or  before  a  particle  of  blood-streaked 
sputum  attracts  his  attention.  The  typical  symptoms,  as  they 
appear  in  pulmonary  tuberculosis  in  early  life,  do  not  occur  in 
the  aged.  The  temperature  is  normal.  There  are  no  night 
sweats,  no  rapid  emaciation,  rarely  secondary  tuberculous 
diseases.  There  is,  however,  dyspnea,  cardiac  palpitation  or 
arrhythmia,  and  the  face  becomes  dusky  or  cyanotic;  but  these 
symptoms  are  usually  attributed  to  the  heart  and  impaired  circu- 
lation. There  is  usually  a  cough,  and  the  expectoration  may  be 
profuse  or  scanty.  In  some  cases  there  is  little  cough  or  expec- 
toration, the  slight  coughing  being  due  to  the  irritation  pro- 
duced by  a  secretion  of  mucus  of  atrophic  bronchitis.  The 
expectoration  is  occasionally  blood-stained,  especially  after 
severe  attacks  of  coughing.  Pulmonary  hemorrhage,  in  which  a 
quantity  of  blood  is  lost,  may  be  due  to  erosion  of  a  blood-vessel, 
to  excessive  or  sudden  strain  or  to  a  sudden  rise  in  blood  pres- 
sure, and  cases  have  been  reported  in  which  there  was  a  rupture 
of  a  varicose  vein  in  the  trachea  and  rupture  of  a  vessel  in  a 
bronchus  while  straining  at  stool.     A  profuse  hemorrhage  is  fatal. 

Late  symptoms  are  cachexia  and  emaciation,  persistent 
dyspnea,  cough  and  expectoration,  the  latter  purulent  or  muco- 
purulent and  occasionally  blood-streaked  and  a  sinking  of  the 
chest  walls  over  the  diseased  part  of  the  lungs.  The  supra- 
clavicular and  infraclavicular  spaces  are  deeply  depressed, 
most  markedly  so  on  the  affected  side.  While  the  respiratory 
movements  in  old  age  produce  a  rise  and  fall  of  the  rigid  chest 
walls  instead  of  an  expansive  movement,  there  may  be  noticed 
during  inspiration  a  retraction  of  the  intercostal  spaces  on  the 
affected  side  and  a  bulging  on  the  unaffected  side.  If  both 
sides  are  affected  the  intercostal  spaces  of  both  will  be  retracted. 
Percussion  gives  dulness  over  the  affected  area,  the  percussion 
sound  during  deep  inspiration  being  shorter,  and  almost  flat. 
There  are,  however,  many  sources  of  error  in  percussing  a  senile 
chest  with  fibrous  phthisis.  Pneumokoniosis,  senile  emphy- 
sema, the  atrophied  lung,  pleuritic  adhesions,  areas  of  hyper- 
emia, and  old  cavities,  all  tend  to  modify  the  percussion  note. 


FIBROID  PHTHISIS  413 

The  auscultatory  signs  are  often  difficult  to  interpret  as  there 
may  be  all  varieties  of  rales  and  breathing,  friction  sounds  and 
murmurs.  Expiration  is  usually  prolonged  and  a  tuberculous 
click  can  often  be  heard  over  a  cavity.  It  resembles  a  single 
coarse  bubbling  rale  but  is  louder  and  deeper  and  is  often  felt 
by  the  patient.  It  is  pathognomonic  of  a  cavity.  The  char- 
acter of  the  rales  depends  upon  the  character  of  the  bronchial 
catarrh,  this  condition  being  almost  always  present,  but  other 
pathological  rale-producing  conditions  may  also  exist,  which 
give  no  other  symptom  than  these  rales.  Radiography  gives 
valuable  information,  light  areas  indicating  cavities,  dark  areas 
indicating  consolidation,  induration  or  growths.  In  all  cases 
the  finding  of  the  bacilli  in  the  sputum  establishes  the  diagnosis, 
although  they  may  be  absent  at  one  examination  and  present  at 
the  next.  The  various  tuberculin  tests  can  be  used,  but  a 
positive  reaction  may  be  due  to  a  former  cured  disease.  There 
are  frequent  complications  arising  from  extension  of  the  tuber- 
cular process.  Hoarseness  and  dysphagia  are  generally  due  to 
laryngeal  tuberculosis,  pain  may  be  due  to  irritation  of  the 
pleura,  to  pressure  upon  a  nerve  or  to  a  neuritis.  There  is  occa- 
sionally a  tubercular  pericarditis,  rarely  with  effusion,  and 
tubercular  ulcers  of  the  intestines  may  occur  especially  in  those 
who  swallow  the  sputum  instead  of  expectorating  it.  Liver  and 
spleen  are  occasionally  enlarged  when  the  circulation  is  impaired 
and  passive  congestions  result  in  the  viscera.  The  presence  of 
the  bacilli  is  the  only  distinctive  feature  by  which  this  disease 
can  be  distinguished  from  fibrous  pneumonia. 

In  the  treatment  of  fibroid  phthisis  in  the  aged  the  same 
general  hygienic  measures  must  be  adopted  as  in  younger  indi- 
viduals. Fresh  dust-free  air  and  sunshine  are  of  the  greatest 
importance.  The  dietary  requires  careful  study  as  the  senile 
digestive  organs  act  more  slowly  and  are  often  perverted,  and 
the  diet  applicable  to  the  young  may  be  wholly  inappropriate 
for  the  aged.  The  milk  and  egg  diet  useful  in  younger  individuals 
soon  becomes  objectionable,  and  the  amount  of  fluid  that  must 
be  taken  imposes  excessive  work  upon  the  circulatory  apparatus 
and  kidneys.  The  food  should  be  easily  digestible,  as  concen- 
trated as  possible,  and  leave  little  waste.  This  excludes  food 
containing  a  large  amount  of  cellulose,  fruits,  jellies,  foods  fried 
in  fat,  and  food  that  must  be  swallowed  in  lumps.     The  cereals 


4I4  PATHOLOGICAL   OLD   AGE 

and  leguminous  vegetables  should  form  the  bulk  of  the  food. 
Meats,  if  given  at  all,  should  be  well  cooked,  and  if  the  teeth 
are  too  defective  for  mastication  it  should  be  omitted  altogether 
or  meat  juice  should  be  substituted.  Persons  accustomed  to 
alcoholic  drinks  need  not  be  deprived  of  them,  but  the  distilled 
liquors  and  wines  should  be  diluted.  If  the  sputum  becomes 
blood-streaked  alcoholics  must  be  omitted. 

Sanitarium  and  health  resort  treatment  is  rarely  required. 
High  altitudes  are  dangerous  for  aged  tuberculosis  cases  and  a 
moist  atmosphere  is  liable  to  raise  the  blood  pressure  and  in- 
crease the  tendency  to  hemorrhage. 

Medicinal  treatment  is  indicated  only  for  the  relief  of  dis- 
tressing symptoms  and  for  complications.  Turpentine,  guaiacol 
and  eucalyptol  may  be  used  by  inhalation  if  there  is  an  irritat- 
ing cough  with  scanty,  tenaceous  secretion,  or  if  the  mucus  has 
a  fetid  odor.  Guaiacol  and  creosote  should  not  be  given  by 
the  stomach  as  they  soon  produce  anorexia  and  may  cause 
gastritis.  They  are  to  be  used  by  the  inhalation  method  which 
is  more  direct  and  more  effectual.  Treatment  by  tuberculin 
has  been  often  quite  successful.  If  the  cough  is  very  distress- 
ing and  prevents  sleep  dionin  or  heroin  in  1/12-  to  1/8-grain 
doses  can  be  given.  Dyspnea  is  seldom  severe  enough  to  re- 
quire treatment  unless  occurring  after  excessive  exercise.  If 
it  becomes  necessary  to  give  relief  for  this  then  the  inhalation 
of  3  minims  of  amyl  nitrite  will  give  immediate  results.  For 
prolonged  treatment  the  nitrite  of  soda  in  1/6-  to  1/2 -grain 
doses  three  times  a  day  should  be  used.  Intestinal  disorders 
are  always  due  to  local  conditions,  generally  to  tubercular 
ulcers,  sometimes  to  excessive  or  improper  food,  or  to  drugs. 
Constipation  may  be  due  to  atonicity  of  the  intestines  or  to 
drug  action.  If  there  is  no  obvious  cause  a  mild  laxative,  such 
as  castor  oil,  should  be  given  and  all  food  and  drugs  withheld 
for  a  day.  If  diarrhea  continues  there  is  a  persisting  local 
cause,  probably  an  ulcer.  In  this  case  intestinal  antiseptics, 
as  salol,  the  sulphocarbolates,  urotropin,  etc.,  should  be  used  in 
combination  with  a  mild  astringent  as  bismuth  subnitrate.  The 
food  should  bepredigested,  or  partly  digested,  or  food  preparations 
which  leave  little  or  no  waste  should  be  used  instead.  Acids  and 
acidulated  drinks  should  be  omitted,  but  buttermilk  may  be  taken. 

Miliary  or  acute  general  tuberculosis  is  rare  in  the  aged  and 
when  it  does  occur  it  is  invariably  fatal.     The  disease  is  always 


ACUTE  GENERAL  TUBERCULOSIS  415 

secondary  to  a  local  infection,  but  this  may  have  been  so  mild 
as  to  have  escaped  detection.  Miliary  tuberculosis  presents 
the  constitutional  symptoms  of  toxemia,  but  the  local  symp- 
toms, arising  from  the  organs  or  tissues  containing  the  tuber- 
culous lesions,  predominate.  These  local  symptoms  are  usually 
severe  results  of  the  primary  infection.  In  some  cases  the  con- 
stitutional symptoms,  chills,  fever,  headache,  prostration,  etc., 
are  severe  from  the  onset,  while  the  local  manifestations  are 
mild,  and  the  patient  passes  rapidly  into  a  typhoid  state.  There 
may  be  then  a  muttering  delirium,  insomnia,  subsultus  ten- 
dinum,  picking  at  the  bed  clothes,  dyspnea,  cyanosis,  a  weak, 
rapid  pulse  but  a  low  temperature,  involuntary  discharge  of 
urine  and  feces  and  rapid  emaciation.  Death  in  these  cases 
occurs  during  the  first  or  second  week.  In  the  aged  the  disease 
usually  assumes  a  toxemic  pulmonary  type  in  which  the  pul- 
monary symptoms  predominate  resembling  acute  lobar  pneu- 
monia or  a  capillary  bronchitis.  The  primary  lesion  in  these 
cases  is  a  fibroid  phthisis  which  is  often  not  recognized  until  the 
acute  miliary  tuberculosis  has  appeared.  In  rare  cases  the 
constitutional  symptoms  are  mild,  fever  is  absent,  but  there  are 
symptoms  of  a  secondary  infection  in  other  tissues,  generally 
in  the  brain.  In  other  cases  the  mild  symptoms  of  a  fibroid 
phthisis  suddenly  become  severe,  there  is  cyanosis,  dyspnea, 
a  hacking,  painful  cough,  blood-streaked  mucopurulent  expec- 
toration, rapid  emaciation  and  loss  of  strength  and  finally, 
death  from  exhaustion.  In  other  forms  of  miliary  tuberculosis, 
the  cerebral  symptoms  predominate  and  the  disease  appears  as 
a  meningitis.  In  others  again  there  is  a  toxemic  pleuritic  form 
and  Ortner  describes  a  marantic  form  which  occurs  in  the  aged. 
The  predominating  symptoms  of  this  are  a  rapid  loss  of  strength 
and  waste  of  tissue  without  marked  local  or  other  constitutional 
manifestations.  In  rare  cases  there  is  an  apparent  improve- 
ment lasting  for  a  day  or  two,  possibly  longer,  with  a  fatal 
relapse.  In  determining  the  diagnosis  the  finding  of  the  patho- 
genic bacillus  is  the  most  important  factor.  Diseases  which 
resemble  it  clinically  in  its  onset  are  influenza,  sepsis,  typhoid 
fever,  pneumonia,  bronchitis,  meningitis,  and  actinomycosis. 
Where  there  is  a  history  of  tuberculosis  the  diagnosis  is  clear. 
In  most  cases  a  bacteriological  test  is  necessary  to  determine 
the  character  of  the  infection,  but  an  early  diagnosis  of  miliary 
tuberculosis  can  often  be  made  by  the  tuberculin  test. 


4i 6  PATHOLOGICAL   OLD    AGE 

Treatment. — There  is  nothing  we  can  do  except  to  relieve 
the  symptoms  and  our  efforts  in  this  direction  often  fail.  Nar- 
cotics and  hypnotics  can  be  used  to  relieve  pain,  insomnia  and 
occasional  delirium,  and  expectorants  or  stimulating  inhalations 
to  increase  and  liquefy  scanty  and  tenaceous  expectoration. 
There  is  nothing  known  that  will  retard  the  rapid  emaciation 
and  loss  of  strength.  Stimulants  are  but  of  momentary  utility, 
the  exhaustion  keeping  pace  with  the  emaciation.  In  diseases 
such  as  this,  which  in  the  present  state  of  knowledge  are  classed 
as  absolutely  fatal,  we  are  justified  in  making  any  experiment, 
however  irrational  it  may  appear,  to  prolong  life.  (This  would 
even  justify  the  implantation  of  the  germs  of  an  antagonistic 
disease  if  the  latter  offers  a  possibility  of  longer  life  than  the 
original  disease.) 

Bone  tuberculosis  is  occasionally  found  in  the  aged,  being 
carried  over  from  earlier  life  either  as  the  continuation  of  a 
slowly  progressive  tubercular  process  or  as  a  recrudescence  of 
the  process  after  years  of  apparent  cure.  In  the  latter  case  the 
disease  is  usually  active,  rapid  in  its  progress,  there  are  many 
foci  in  the  bones  and  organs,  emaciation  and  debility  proceed 
rapidly  and  the  patient  succumbs  in  a  few  weeks  or  months. 
In  the  slowly  progressive  form  the  disease  may  appear  in  the 
bony  structure  secondary  to  visceral  tuberculosis  or  it  may  be 
the  continuation  of  an  original  bone  tuberculosis,  usually  a 
Pott's  disease.  The  secondary  disease  usually  attacks  the  foot, 
knee,  hip,  wrist  or  elbow.  Tuberculosis  in  these  locations  is 
frequently  mistaken  for  rheumatic  arthritis  or  chronic  rheuma- 
tism, occasionally  for  syphilis,  osteomyelitis,  rarely  for  sarcoma. 
The  diagnosis  should  not  be  difficult  if  we  remember  that  tuber- 
culosis and  syphilis  give  histories  pointing  to  these  diseases,  that 
rheumatic  arthritis  produces  characteristic  deformities,  that  the 
tubercular  joint  is  always  swollen,  blanched  and  has  painful 
points.  The  pain  is,  however,  never  as  severe  as  in  osteomyelitis. 
The  history  alone  will  usually  suffice  to  determine  the  diagnosis, 
but  to  clear  up  all  doubts  the  tuberculin  test  may  be  necessary. 

Pott's  disease  is  usually  carried  over  from  maturity.  When 
originating  in  advanced  age  its  progress  is  rapid,  there  is  con- 
siderable pain,  the  normal  spinal  curve  becomes  altered,  a  dis- 
tinct bend  being  found  at  the  site  of  the  bone  lesion ;  occasionally 
there  is  abscess  formation,  and  there  is  marked  cachexia.  A 
neural  form  of  vertebral  tuberculosis  is  described  in  which  the 


Femur,  head  and  neck;  beginning  tuberculosis. 
A.  Small  area  of  caseation  in  epiphysis  just  under 
articular  cartilage,  called  subchondral.  B,  B.  Same 
in  epiphyses  at  point  of  junction  with  shaft;  intraos- 
seous. C.  Subperiosteal.  {After  McArdle  (redrawn) 
"Trans.  Royal  Acad,  of  Med.  in  Ireland,"  vol.  vii, 
1889,  p.  140.) 


CEREBROSPINAL  MENINGITIS  417 

only  symptoms  are  those  of  myelitis  and  neuritis.  The  diagnosis 
must  be  made  by  excluding  the  various  forms  of  spinal  sclerosis 
and  other  diseases  giving  localized  spinal  pain.  Pic  says  radio- 
graphy performs  a  great  service  in  diagnosing  this  form  of  Pott's 
disease.  There  is  also  a  latent  form  of  vertebral  tuberculosis  which 
gives  no  marked  symptoms,  but  the  lesion  is  found  after  death. 

The  treatment  of  bone  tuberculosis  in  the  aged  is  the  same  as 
in  younger  individuals. 

Relapsing  fever  does  not  occur  in  the  United  States  and  is  infre- 
quent in  the  aged  even  in  countries  where  it  is  met  with.  Accord- 
ing to  Ortner  it  does  not  differ  from  the  disease  as  it  occurs  in 
earlier  life,  except  that  it  is  more  fatal  in  the  old  owing  to  the 
grave  secondary  complications,  pulmonary  disease,  suppurative 
parotitis  and  cardiac  exhaustion.  Experimental  treatment 
with  an  antispirochetic  serum  has  been  reported  favorably. 

Miliary  fever  and  Malta  fever  do  not  occur  in  United  States 
and  are  rare  in  the  aged  in  countries  where  they  are  epidemic. 

Cerebrospinal  meningitis  is  rare  in  old  age,  only  i  per  cent, 
of  the  cases  reported  in  the  last  New  York  epidemic  occurring 
in  persons  over  50  years  of  age.  The  disease  presents  some 
minor  differences  in  symptomatology  from  the  disease  in  younger 
individuals.  It  begins  usually  with  slight  chills,  the  temperature 
is  but  little  higher  than  normal,  and  in  some  cases  may  be 
normal  or  subnormal.  The  pain  in  the  lumbar  regions  appears 
early,  is  intense,  and  proceeds  rapidly  upward  along  the  spine. 
The  rigidity  of  the  muscles  of  the  neck  usually  appears  on  the 
first  day  and  prevents  forward  and  backward  motion,  but 
lateral  motion  may  not  be  impaired  for  several  days.  Opis- 
thotonus is  rare.  The  cerebral  symptoms  are  severe  from  the 
onset  of  the  disease.  These  are  intense  headache,  photophobia, 
unequal  dilatation  of  the  pupils,  impairment  of  the  motor 
oculi,  perhaps  strabismus,  nystagmus  or  ptosis,  sometimes 
acute  oversensitiveness  of  hearing,  but  more  often  deafness. 
In  some  cases  there  is  paralysis  of  the  facial  and  trifacial 
nerves,  and  the  senses  of  taste  and  of  smell  become  blunted. 
The  tendon  reflexes  are  diminished  and  may  be  abolished.  Der- 
mographia  and  facial  herpes  are  frequently  present.  Kernig's 
sign  is  always  positive.  Pulse  and  respiration  are  accelerated, 
weak  and  irregular  and  Cheyne-Stokes  respiration  sometimes 
occurs  shortly  before  death.  There  is  almost  always  a  rapid 
27 


4i 8  PATHOLOGICAL   OLD    AGE 

loss  of  weight.  Remissions  occasionally  occur  and  during 
apparent  convalescence  the  symptoms  will  suddenly  return 
with  increased  violence;  in  most  cases,  however,  the  disease 
progresses  rapidly,  delirium  and  then  coma  follow  and  the 
patient  dies.  A  case  may  be  protracted  for  several  weeks, 
death  finally  ensuing  as  a  result  of  exhaustion,  pulmonary 
edema,  or  other  complication.  Many  cases  die  before  it  is 
possible  to  make  a  positive  diagnosis.  The  presence  of  Kernig's 
sign  points  to  meningeal  disease  and  the  prevalence  of  an  epi- 
demic is  presumptive  evidence  of  the  existence  of  the  disease 
if  there  is  prostration,  lumbar  pain  and  rigidity  of  the  muscles 
of  the  neck.  The  onset  in  the  aged  is  almost  always  clearly 
marked  and  can  generally  be  diagnosed  without  the  necessity 
of  making  a  lumbar  puncture  to  determine  the  character  of 
the  germs  present.  The  finding  of  the  diplococcus  of  Weichsel- 
baum  in  the  cerebrospinal  fluid  or  in  the  secretion  of  the  nose 
makes  the  diagnosis  certain.  In  the  treatment  of  cerebrospinal 
meningitis  good  results  have  been  obtained  from  the  use  of  the 
Flexner  antimeningitis  serum.  In  the  pandemic  of  1904  to 
1908,  the  mortality  where  it  was  used  was  less  than  25  per  cent., 
while  where  it  was  not  used  the  mortality  was  70  per  cent. 
It  was  less  effective  in  senile  cases  than  in  younger  ones.  Lum- 
bar puncture  with  the  withdrawal  of  from  20  to  40  c.c.  of  cere- 
brospinal fluid,  replacing  it  by  a  like  amount  of  normal  saline 
solution,  often  relieves  the  symptoms  temporarily.  The  pro- 
cedure must  be  repeated  every  second  day.  Ortner  combines 
the  two  methods  of  treatment,  replacing  the  withdrawn  fluid 
by  the  antimeningitis  serum.  The  hot  bath  treatment  and 
Bier's  hyperemia  treatment  cannot  be  applied  to  the  aged, 
owing  to  the  impaired  circulation.  Local  disinfection  of  the 
throat  and  nose  by  means  of  peroxide  of  hydrogen  is  beneficial 
as  a  prophylactic  measure.  The  treatment  of  the  symptoms 
is  directed  principally  to  relieve  the  cerebral  manifestations. 
The  most  important  of  these  measures  is  the  application  of  cold 
water,  not  ice,  to  the  head  and  neck.  This  must  be  used 
continuously  during  the  disease.  Other  remedies  for  the 
relief  of  the  insomnia,  headache,  neuralgias,  constipation,  etc., 
must  be  selected  with  due  regard  to  the  condition  of  the  heart 
and  blood-vessels.  Veronal,  morphine  combined  with  atropinf 
the  bromides  and  aspirin  may  be  used. 


ERYSIPELAS  419 

Acute  articular  rheumatism  is  almost  always  a  recrudes- 
cence of  a  former  attack.  The  symptoms  do  not  differ  from 
the  disease  in  earlier  life.  In  some  cases  there  is  little  fever  or 
swelling  of  the  joints,  but  there  is  the  same  pain  and  stiffness. 
Occasionally,  fever  precedes  the  acute  attack,  and  this  pro- 
dromal fever  may  be  higher  than  the  fever  that  usually  accom- 
panies the  involvement  of  each  new  joint.  In  other  cases  there 
are  marked  cerebral  symptoms,  with  hyperpyrexia  showing  a 
severe  toxemia.  These  cases  are  grave,  since  they  sometimes 
proceed  to  delirium,  followed  by  coma  and  death.  Acute  endo- 
carditis, myocarditis  and  pericarditis,  which  are  frequent  com- 
plications of  acute  articular  rheumatism  in  earlier  life,  are  rare 
in  the  aged.  The  only  serious  complication  that  occurs  fre- 
quently is  hypostatic  congestion  followed  by  pulmonary  edema, 
and  this  can  usually  be  avoided. 

The  only  disease  which  may  be  mistaken  for  acute  articular 
rheumatism  is  gout  and  the  differentiation  should  present  no 
difficulty  if  we  remember  that  gout  generally  affects  the  small 
joints,  that  intense  exacerbations  generally  occur  at  night,  and 
that  there  may  be  gouty  deposits  and  a  clear  history  of  gout. 

The  treatment  of  acute  articular  rheumatism  in  the  aged 
is  the  same  as  in  younger  individuals.  The  aged  require  large 
doses  of  the  salicylates,  about  20  grains  every  four  hours ;  and 
morphine  may  be  given  if  the  pain  is  severe.  The  iodides  are 
worthless  in  this  disease  in  the  aged. 

Erysipelas  occurs  frequently  in  persons  of  advanced  years. 
Its  favorite  location  is  about  the  lower  extremities,  and  it  ap- 
pears there  more  frequently  than  in  maturity,  but  it  may  also 
occur  about  the  buttocks,  face,  head,  hands  and  other  portions 
of  the  body.     The  prevalence  of  erysipelas  about  the  lower 
extremities  is  explained  by  the  frequency  of  excoriations,  vari- 
cose ulcers,  eczema,  scratches  and  abrasions,  following  pruritus 
in  that  locality.     When  occurring  about  the  buttocks  it  follows 
bed  sores;  when  on  the  face  it  follows  some  slight  lesion  about 
the  nose,  eye,  corner  of  the  mouth  or  elsewhere.     Erysipelas 
of  the  scalp  is  usually  an  extension  of  the  disease  from  the  face. 
The  source  of  infection  in  every  case  is  a  local  primary  lesion 
which  may  have  been  so  insignificant  that  it  escaped  notice. 
Lack  of  cleanliness  is  a  contributing  factor  in  most  cases.     Ow- 
ing to  the  senile  changes  in  the  skin — atrophy  of  subcutaneous 


420  PATHOLOGICAL   OLD   AGE 

tissue,  partial  obliteration  of  capillaries,  and  diminished  surface 
circulation — the  local  symptoms  are  generally  modified.  The 
redness  is  not  as  intense  as  in  maturity,  there  being  less  infil- 
tration and  swelling  and  little  or  no  elevation  of  temperature 
in  the  affected  part.  It  is  frequently  localized  in  a  small  area, 
and  spreads  slowly.  In  some  cases  there  are  patches  of  ery- 
thema joined  by  fine  reddish  lines.  It  rarely  spreads  by  the 
lymph  spaces,  mostly  by  surface  extension.  Sensations  of 
heat  and  pain  are  much  slighter  than  in  earlier  life  and  but 
rarely  is  there  any  involvement  of  the  local  lymphatics.  Ves- 
icles, blebs,  and  pustules  are  seldom  seen,  but  gangrene  may 
occur  in  localities  where  the  circulation  is  greatly  impaired. 
The  constitutional  symptoms,  like  the  local  ones,  are  much 
milder  in  the  aged  than  in  earlier  life.  The  onset  may  be 
abrupt,  with  a  severe  chill;  more  often  there  are  slight  chilly 
sensations  followed  by  a  rapid  rise  in  temperature.  The  latter 
may  be  but  little  raised,  rarely  higher  than  1020.  The  pulse 
and  respiration  are  accelerated,  but  after  defervescence  of 
the  eruption  the  pulse  becomes  slow  and  may  drop  to  50  per 
minute  while  the  temperature  may  sink  to  950.  Erysipelas  of 
the  face  is  often  accompanied  by  bronchial  catarrh;  while 
erysipelas  of  the  scalp  is  generally  accompanied  by  cerebral 
symptoms  such  as  intense  headache,  delirium,  delusions,  hallu- 
cinations, insomnia,  etc.  Albuminuria  is  generally  present 
but  other  complications,  which  usually  accompany  infectious 
diseases,  are  rare.  Relapses,  however,  may  occur  after  an 
apparently  complete  recovery,  and  recrudescence  months  or 
years  after  the  original  disease  had  disappeared  is  not  rare. 

The  treatment  of  erysipelas  is  prophylactic,  curative,  symp- 
tomatic and  hygienic.  The  principal  prophylactic  measures 
are  cleanliness;  antiseptic  treatment  of  all  wounds,  ulcers, 
excoriations  and  scratches  and  the  quarantine  of  cases  when 
they  occur  in  institutions.  The  curative  measures  include 
serum  therapy,  which  is  still  in  an  experimental  stage,  and 
measures  to  localize  and  diminish  the  eruption.  For  this 
purpose  ichthyol  is  probably  the  most  effective.  It  is  brushed 
thickly  over  the  affected  area,  covered  with  cotton,  and  allowed 
to  remain  until  twenty-four  hours  after  all  local  and  constitu- 
tional symptoms  have  disappeared.  This  is  superior  to  resorcin, 
guaiacol,  nitrate  of  silver,  or  tincture  of  iron,  the  drugs  that 


SEPSIS  421 

were  formerly  employed  for  the  purpose.  Hot  fomentations 
sometimes  relieve  local  pain,  but  they  do  not  improve  the  general 
condition.  Carbolic  acid,  the  lead,  mercury,  silver,  and  other 
metallic  salts  are  contraindicated  in  the  aged.  For  the  relief 
of  distressing  symptoms,  like  headache,  fever,  insomnia,  pain, 
etc.,  the  usual  remedies  for  such  conditions  are  required.  Cold 
applications,  not  ice,  can  be  applied  to  the  head  if  cerebral 
symptoms  appear.  For  the  fever  the  preferable  drug  is  quinine 
or  salicylate  of  soda,  but  none  of  the  coal-tar  preparations 
should  be  used.  Veronal  may  be  given  for  insomnia.  If  local 
pain  is  severe,  hot  applications  of  tincture  of  opium  or  a  5  per 
cent,  cocaine  ointment  can  be  applied.  Internal  analgesics  are 
seldom  required.  The  hygienic  regulations  require  only  a 
nutritious  diet  with  little  carbohydrate  and  no  hydrocarbons; 
care  of  the  bowels  and  kidneys,  drinking  large  quantities  of 
alkaline  water  if  the  renal  secretion  is  deficient  in  quantity,  and 
observance  of  the  ordinary  rules  of  health. 

SEPSIS 

Sepsis  is  used  here  to  include  septicemia  and  pyemia.  Much 
confusion  has  arisen  through  different  interpretations  given  to 
these  and  their  allied  terms  toxemia,  bacteremia  and  septico- 
pyemia. The  last  of  these  terms  is  superfluous,  as  every 
pyemia  is  septic  and  produces  symptoms  of  septicemia.  The 
term  toxemia  is  usually  applied  to  a  condition  in  which  bacterial 
toxins  exist  in  the  blood  and  bacteremia  is  applied  to  a  condi- 
tion in  which  the  bacteria  themselves  are  present  in  the  circula- 
tion. Septicemia  is  applied  in  its  broadest  sense  to  the  disease 
produced  by  toxemia  or  bacteremia,  while  in  its  narrowest  sense 
it  is  restricted  to  the  disease  caused  by  pus-forming  germs 
or  their  toxins  before  secondary  foci  of  suppuration  have  de- 
veloped. A  localized  pus  formation  in  which  the  local  symptoms 
predominate  receives  a  local  appellation  as  pyelitis,  purulent 
pleurisy,  abscess  of  the  lung,  etc.  When  the  pus  is  carried  in 
the  blood  and  deposited  in  various  localities,  and  the  systemic 
symptoms  predominate,  the  disease  is  pyemia.  In  furunculosis, 
for  example,  there  are  many  local  pus  deposits  but  the  systemic 
symptoms  are  mild.  Pathologically  it  is  a  pyemia,  clinically 
it  is  not.     Ortner  rejects  the  term  pyemia  and  speak  of  it  as 


422 


PATHOLOGICAL   OLD    AGE 


metastatic  sepsis,  reserving  the  term  true  sepsis  for  septicemia. 
Other  writers  take  different  views. 

Sepsis  like  most  other  infectious  diseases  is  infrequent  in 
the  aged  and  when  it  does  occur  it  runs  an  atypical  course. 
The  usual  channels  of  infection  in  the  aged  are  surface  lesions 
such  as  chronic  ulcers,  eczema,  erosions,  scratches,  bed  sores, 
etc.,  or  the  bladder  infected  by  catheterization.  Less  frequently 
the  channel  of  infection  is  the  lower  bowel,  the  nose,  mouth, 
respiratory  or  digestive  tract.  In  some  cases  the  source  of 
infection  is  in  the  gall-bladder  or  in  the  ducts,  rarely  in  the 
serous  membranes. 

The  symptoms  of  septic  infection  in  the  aged  differ  somewhat 
from  those  of  earlier  life,  the  most  pronounced  differences 
being  in  the  lower  temperature  and  more  frequent  cerebral 
symptoms.  Even  in  a  grave  form  of  sepsis  the  temperature 
rarely  exceeds  1030.  When  due  to  the  streptococcus  the 
temperature  is  irregular,  sometimes  it  is  continuous  for  days, 
sometimes  remittent  or  intermittent.  The  bacillus  coli  produces 
an  irregular  temperature  with  frequent  slight  chills,  the  tem- 
perature rising  after  each  chill,  then  dropping  until  the  next 
chill  occurs.  In  some  cases  these  chills  come  on  at  quite 
regular  intervals  and  there  is  then  a  fairly  regular  rise  and  fall 
of  temperature.  The  same  condition  may  also  be  due  to 
staphylococcic  infection  and  this  has  been  considered  as  dis- 
tinctive of  pyemia.  In  many  senile  cases  of  sepsis  the  tem- 
perature does  not  rise  above  98. 50.  There  is  rapid  heart  action 
and  rapid  respiration  in  spite  of  the  low  temperature,  frequently 
dyspnea,  weak  pulse  and  always  some  cerebral  disturbance. 
This  is  generally  evidenced  by  severe  headache  and  insomnia, 
sometimes  by  more  profound  disturbances  such  as  photophobia, 
delirium  and  coma,  involuntary  discharge  of  feces  and  urine, 
and  great  prostration.  The  blood  changes  are  generally  similar 
to  those  of  maturity  but  in  debilitated  patients,  especially  if 
the  infection  is  severe,  leucopenia  may  exist  from  the  onset  of 
the  disease  or  may  appear  after  a  short  leucocytosis.  The 
spleen  is  rarely  found  enlarged,  but  this  is  only  relative  as  the 
senile  spleen  is  normally  diminished  in  size.  Constipation  is 
usual  owing  to  intestinal  paresis.  The  cutaneous  manifestations 
frequently  found  in  earlier  life  are  rare,  except  a  temporary 
herpes,  erythema  or  a  roseola.     The   most   serious   and   most 


SEPSIS 


423 


frequent  complication  of  sepsis  is  septic  endocarditis.  Apart 
from  the  danger  to  the  heart  itself,  septic  endocarditis  gives  rise 
to  emboli  which  may  be  carried  to  any  of  the  tissues,  producing 
infarcts,  abscesses,  and  hemorrhages.  Abscess  formation  occurs 
most  frequently  with  staphylococcic  infection.  The  abscesses 
are  usually  small  and  scattered  throughout  the  tissues  so  that 
their  exact  location  cannot  be  determined.  Occasionally  an 
abscess  is  limited  to  a  single  organ  such  as  the  lung,  or  occurs 
in  a  single  tissue  such  as  a  joint,  or  will  burrow  through  ad- 
joining tissue  and  form  a  pocket  at  some  distance  from  the 
original  site.  Occasionally  a  local  septic  inflammation  with 
pus  formation  will  destroy  the  enclosing  tissue  and  the  pus 
pouring  into  one  of  the  large  cavities  causes  a  septic  peritonitis, 
pleurisy,  cellulitis,  etc. 

Sepsis  in  the  aged  is  usually  fatal.  It  will  not  occur  unless 
the  resistance  of  the  body  is  lowered  and  that  alone  implies 
lowered  vitality.  In  the  cases  where  surgical  measures  can  be 
taken  to  empty  pus  depots,  recovery  may  follow.  Where 
such  depots  cannot  be  reached  or  where  there  is  a  virulent, 
non-suppurative  septic  infection  a  fatal  issue  may  be  expected. 
How  far  serum  therapy  will  modify  the  prognosis  is  uncertain. 
In  this,  as  in  all  other  infectious  diseases  of  the  aged,  the  pro- 
found physical  depression  is  of  graver  import  than  the  local 
action  of  the  germs.  The  prostration  is  often  far  greater  than 
the  extent  or  virulence  of  the  infection  would  account  for  and 
persists  after  the  disease  germs  have  disappeared.  Serum 
therapy  of  the  future,  if  effectual,  will  destroy  further  germ 
activity  and  shorten  the  length  of  exposure  of  tissue  to  the 
deleterious  influences  of  the  germs,  thereby  removing  complicat- 
ing factors. 

The  invasion  of  most  infectious  diseases  in  the  aged  gives 
a  very  similar  symptomatology  and  only  bacteriological  exam- 
ination can  determine  an  early  diagnosis.  In  a  mild  pyogenic 
infection  there  will  be  found  a  leucocytosis.  This  excludes 
typhoid  fever,  malaria,  acute  tuberculosis,  influenza,  and 
measles.  In  a  virulent  infection  there  is  leucopenia  with  rela- 
tive increase  of  polynuclear  leucocytes,  while  in  the  leucopenia 
of  typhoid  fever  the  lymphocytes  are  relatively  increased.  The 
Widal  test  and  diazo  reaction  will  differentiate  typhoid 
fever.     In  the  latter  disease  the  initial  prostration  is  more  pro- 


424 


PATHOLOGICAL   OLD    AGE 


found,  the  abdominal  symptoms  appear  early  and  there  are 
rarely  chills,  herpes,  or  the  rapid  pulse  and  respiration  found 
in  sepsis.  When  typhoid  fever  and  sepsis  are  present  at  the 
same  time  the  typhoid  symptoms  will  completely  mask  the 
symptoms  of  sepsis  unless  abscesses  form.  The  early  differential 
diagnosis  between  sepsis  and  miliary  tuberculosis  may  sometimes 
be  made  by  the  history  either  of  a  fibroid  phthisis  or  other 
form  of  tuberculosis,  or  else  of  a  surface  lesion.  Cyanosis 
and  cough  occur  early  in  acute  tuberculosis;  late,  if  at  all,  in 
sepsis.  The  absence  of  catarrhal  symptoms  will  exclude 
influenza,  and  malaria  can  generally  be  excluded  by  the  history 
and  the  condition  of  the  patient  after  the  attack. 

The  present-day  treatment  of  sepsis  is  by  serum  therapy. 
The  frequent  failures  where  serums  and  vaccines  are  used  arise 
from  using  a  single  strain  of  polyvalent  vaccine  in  cases  in 
which  several  forms  of  bacteria  are  active.  Success  by  this 
method  of  treatment  can  be  achieved  only  when  we  know  the 
kind  of  bacteria  we  are  dealing  with  and  for  that  reason  a 
bacteriological  examination  should  be  made  before  we  select 
the  serum  or  vaccine.  A  combined  vaccine  can  be  used  if 
several  forms  of  bacteria  are  found.  In  advanced  arterio- 
sclerosis and  weak  heart  the  sera  and  vaccines  are  contraindi- 
cated.  (French  physicians  recommend  as  a  curative  measure 
the  subcutaneous  injection  of  colloidal  metals  such  as  elec- 
trargol,  electroplatinol,  etc.  Their  therapeutic  value  is  uncer- 
tain, however.) 

Other  measures  in  sepsis  are  either  surgical  or  measures 
for  the  relief  of  symptoms. 

In  the  treatment  of  symptoms  we  must  bear  in  mind  the 
senile  changes.  We  must  not  use  powerful  vasoconstrictors 
like  digitalis,  nor  cardiac  depressants  like  the  coal  tar  products 
and  chloral,  nor  drugs  which  inhibit  peristalsis  like  belladonna 
and  opium.  Cold  baths  may  produce  a  fatal  shock  and  ice 
may  destroy  the  surface  circulation.  The  safest  drug  for 
reducing  the  temperature  is  quinine.  Its  action,  however, 
is  slow  and  it  frequently  causes  gastric  irritation.  Heart 
tonics  are  required  from  the  onset  of  the  disease.  The  most 
available  is  caffein  or  coffee.  In  threatened  heart  failure 
we  can  use  camphor,  ether,  or  strychnine  hypodermically. 
For   the   cerebral   symptoms   cold   applications   to   the   head, 


GONORRHEAL  INFECTION  425 

and   the  bromides  internally,    and   for  insomnia   we   can   use 
veronal  or  urethane. 

Care  should  be  taken  to  secure  free  bowel  and  kidney- 
action.  Any  of  the  peristaltic  stimulants  as  aloin,  cascara, 
castor  oil,  etc.,  can  be  employed  to  prevent  constipation,  and 
for  the  kidneys  nothing  will  take  the  place  of  water.  It  can 
be  taken  in  small  quantities  in  short  intervals,  never  in  large 
quantities  at  a  time,  or  it  may  be  given  by  large  rectal  enemata 
slowly  delivered  several  times  a  day.  Where  surgically  ac- 
cessible pus  depots  exist,  these  should  be  cleaned  out.  When 
death  without  operation  appears  inevitable  the  most  desperate 
surgical  measures  may  sometimes  succeed. 

Gonorrheal  infection  is  rare  in  the  aged  as  they  expose  them- 
selves less  and  there  is  apparently  less  susceptibility  to  the 
disease.  Various  hospital  and  dispensary  statistics  place  the 
number  of  cases  of  gonorrhea  between  fifty-one  and  sixty 
years  of  age  at  little  over  i  per  cent,  of  the  whole  number  of 
cases  seen  and  above  sixty  years  of  age  at  a  small  fraction  of 
1  per  cent.  Gonorrhea  in  the  aged  female  is  extremely  rare. 
The  symptoms  do  not  differ  from  those  of  earlier  life.  The 
disease  is  usually  milder,  but  less  amenable  to  treatment  and 
is  often  followed  by  a  postgonorrheal  urethritis,  but  seldom  by 
a  prostatitis  or  stricture.  Other  complications  are  rare.  An 
infectious  non-gonorrheal  discharge  simulating  gonorrhea  is 
sometimes  found  in  those  who  fail  to  observe  antiseptic  pre- 
cautions when  using  the  catheter.  The  diagnosis  in  such  a 
case  rests  upon  the  bacteriological  findings.  Prostatorrhea, 
spermatorrhea  and  simple  urethritis  may  occur  in  the  aged 
and  give  rise  to  the  suspicion  that  a  gonorrhea  exists.  These 
all  require  a  microscopic  examination  to  determine  their  char- 
acter. When  a  stricture  is  suspected  a  sound  must  be  used. 
The  stricture  may  be  simulated  by  urethral  spasm  and  com- 
pression of  the  urethra  by  a  hypertrophied  prostate.  The 
former  disappears  after  an  injection  of  a  2  per  cent,  solution 
of  cocaine  in  warm  water.  The  latter  gives  other  symptoms 
pointing  to  an  enlarged  prostate,  while  the  history  of  gonor- 
rheal infection  is  absent.  A  postgonorrheal  stricture,  however, 
may  exist  at  the  same  time  with  a  hypertrophied  prostate. 

The  treatment  of  gonorrhea  in  the  aged  is  the  same  as  in 
young  individuals.     If  there  is  a  stricture,  slow  dilatation  by 


426  PATHOLOGICAL    OLD   AGE 

means  of  sounds  is  better  than  the  more  rapid  divulsion  or  in- 
cision methods. 

General  infection,  gonorrheal  toxemia,  gonorrheal  arthritis, 
gonorrheal  endocarditis  and  gonorrheal  neuritis,  etc.,  are  ex- 
tremely rare  in  the  aged.  They  must  be  considered  among 
the  possibilities,  however,  where  there  is  a  toxemia,  arthritis, 
endocarditis,  neuritis,  etc.,  of  unknown  origin,  but  unless  the 
specific  organism  is  isolated  in  the  blood  or  synovial  fluid,  we 
cannot  make  a  diagnosis  of  systemic  gonorrheal  infection.  If 
the  diagnosis  has  been  confirmed,  we  can  use  the  gonorrheal 
vaccine,  subcutaneously,  as  a  curative  measure.  The  septic 
and  endocardial  forms  are  usually  fatal. 

SYPHILIS 

Syphilis  is  seldom  acquired  in  advanced  age.  Persons 
having  congenital  syphilis  rarely  reach  old  age  and  old  people 
do  not  expose  themselves  to  the  danger  of  infection  as  often  as 
younger  persons.  Fournier  reports  of  10,000  cases,  207  between 
the  ages  of  51  and  61  and  40  between  the  ages  of  61  and  71. 
Tertiary  syphilis  occurs  more  frequently,  hospital  records 
showing  from  8  to  13  per  cent,  over  the  age  of  50;  of  these,  1  to 
3  per  cent,  were  between  60  and  70,  and  a  small  fraction  of  1  per 
cent,  over  70.  In  many  senile  cases  the  disease  is  acquired 
accidentally  in  old  age  and  does  not  differ  then  materially  from 
the  disease  in  younger  individuals.  Sometimes  the  period  of 
incubation  is  prolonged  and  the  initial  lesion  persists  longer. 
The  sore  is  often  larger  and  deeper  than  in  maturity,  it  looks 
raw  and  in  some  cases  it  becomes  gangrenous.  The  disease  on 
the  whole  is  usually  more  severe  than  in  younger  persons  and 
secondary  lesions  may  appear  before  the  primary  chancre  has 
disappeared.  The  lymphatics  become  very  slowly  and  at 
times  not  severely  involved,  but  the  cutaneous  and  nervous 
manifestations  are  more  pronounced  than  in  earlier  life.  A 
diffuse  papulopustular  syphilide  is  common.  Syphilitic  iritis 
is  an  early  manifestation  of  the  second  stage.  There  is  no  sharp 
dividing  line  between  the  second  and  the  third  stages,  the 
disease  in  the  aged  usually  progressing  without  intermission. 
The  pustules  become  ulcers,  gummata  form,  the  internal  vis- 
cera become  affected  early,  usually  by  the  production  of  syphi- 
litic ulcers,  the  syphilitic  cachexia  is  pronounced  and  often 
leads  to  fatal  exhaustion.     Quinquard  found  a    constant  de- 


SYPHILIS  427 

crease  of  the  red  blood  cells,  hemoglobin  and  of  the  albuminoids 
of  the  serum,  the  red  cells  numbering  as  low  as  2,000,000.  The 
central  nervous  system  is  often  profoundly  affected,  and  there 
is  usually  mental  depression,  irritability,  headache,  sometimes 
insomnia  and  vertigo. 

In  some  cases  the  invasion  of  the  secondary  stage  is  like  the 
invasion  of  an  eruptive  fever,  with  chills,  fever,  prostration, 
headaches,  etc.,  and  only  the  history,  the  Wasserman  test,  or 
the  finding  of  the  spirocheta  will  determine  the  diagnosis  of 
syphilis.  While  French  physicians  generally  ascribe  greater 
virulence  to  the  disease  acquired  in  old  age,  the  opposite  view 
is  held  by  German  physicians.  American  physicians  who  see 
many  syphilitic  cases  confirm  the  French  view.  The  disease, 
however,  does  occasionally  appear  in  a  mild  form  in  the  aged, 
the  initial  lesion  is  small,  the  secondary  symptoms  begin  with  a 
slight  roseolar  rash,  the  mucous  membranes  are  not  affected, 
there  are  no  pains  in  the  bones  or  joints,  and  tertiary  symptoms 
do  not  appear.  Fournier  described,  under  the  name  La  Cachaxie 
adynamique,  a  rare  form  of  syphilis  in  the  aged.  In  this  form 
there  are  pronounced  constitutional  symptoms  with  little  or  no 
local  ones,  except  the  initial  chancre.  There  are  mental  and 
physical  depression,  anemia,  anorexia,  somnolence,  progressive 
emaciation  and  exhaustion.  In  severe  cases  the  fatal  issue  is 
reached  in  a  few  months,  more  protracted  cases  may  last  two  or 
three  years,  death  being  due  to  exhaustion  or  pulmonary  edema. 
Most  cases  of  syphilis  in  the  aged  resemble  the  third  stage  of  a 
syphilis  which  had  been  apparently  cured  years  before.  Four- 
nier reported  a  case  in  which  the  tertiary  lesions  appeared 
fifty-five  years  after  the  infection.  In  these  delayed  cases  of 
tertiary  syphilis  the  disease  is  generally  mild  and  is  confined  to 
one  locality  or  tissue  such  as  the  skin,  mucous  membrane,  bone, 
etc.  If  a  viscus  is  affected  it  is  generally  by  a  chronic  syphilitic 
ulcer,  which  gives  little  pain  and  no  other  clear  symptom. 

The  finding  of  the  spirochetal  in  the  blood  establishes  the 
diagnosis  with  positiveness.  If  these  are  absent  we  can  use 
the  Wassermann  reaction.  A  positive  reaction  means  a  positive 
diagnosis,  but  we  may  get  a  negative  reaction  though  the  disease 
be  present.  If  both  of  these  methods  fail  we  have  still  the  his- 
tory of  exposure  and  initial  lesion.  This  initial  chancre  is 
present  in  every  case,  but  its  site  is  not  necessarily  confined  to 
the  genital  organs.     Aside  from  the  rare  cases  of  syphilis  inson- 


428  PATHOLOGICAL   OLD    AGE 

Hum  or  accidentally  acquired  syphilis,  the  frequency  of  sexual 
perversions  in  the  aged,  in  whom  the  potentia  coeundi  has 
diminished,  gives  rise  to  unusual  locations  of  infection.  The 
unreliability  of  such  perverts  makes  the  history,  as  obtained 
from  them,  unreliable.  A  chancre  should,  however,  give  no 
difficulty  in  diagnosis  and  it  is  only  after  secondary  or  tertiary 
lesions  arise,  and  history,  as  well  as  bacteriological  examination, 
and  Wassermann  reaction  are  all  negative  that  there  can  be  any 
question  as  to  the  correctness  of  the  diagnosis.  During  the 
second  stage  the  brownish  spots,  mucous  patches,  atrophy  of  the 
glands  at  the  base  of  the  tongue  and  enlargement  of  lymphatic 
glands  form  a  pathognomonic  symptom- complex.  Should  there 
be  any  question  of  diagnosis  in  the  tertiary  stage  we  will  usually 
be  able  to  get  a  history  of  the  symptoms  of  the  secondary  stage 
even  if  an  initial  chancre  is  denied.  In  questioning  the  aged 
where  there  is  a  suspicion  of  syphilis,  more  truthful  replies  will 
be  obtained  if  we  enquire  about  the  secondary  lesions  without 
explaining  the  purpose  of  the  questions,  for  they  will  generally 
deny  having  had  a  venereal  disease.  The  tertiary  symptoms 
in  the  aged  are  frequently  misleading.  Syphilitic  eruptions 
and  sores  do  not  itch,  but  the  aged  often  suffer  from  a  pruritus 
independent  of  syphilis  and  the  cutaneous  lesions  may  then  itch. 
Sclerotic  degenerations  are  more  often  due  to  senile  changes 
than  to  syphilis  and  the  same  applies  to  anemia,  emaciation, 
albuminuria,  constipation,  valvular  diseases,  all  of  them  condi- 
tions which  may  be  due  to  syphilis,  yet  which  are  found  nor- 
mally in  the  aged.  They  may  also  occur  in  tuberculosis  and  the 
differentiation  between  a  tuberculous  ulcer  and  a  syphilitic 
ulcer  will  sometimes  be  impossible  without  a  bacteriological 
examination,  the  Wassermann  test  or  the  tuberculin  test.  If 
all  these  diagnostic  methods  fail  we  must  use  the  red  or  yellow 
iodide  of  mercury  and  observe  the  result,  an  improvement  occur- 
ring in  syphilis  but  not  in  tuberculosis. 

The  treatment  of  syphilis  in  the  senescent  is  the  same  as 
in  maturity.  The  older  method  of  treatment  with  mercury 
and  the  iodides  is  still  the  most  reliable  one  and  with  slight 
modifications  can  be  applied  to  the  aged.  The  mercury  should 
be  used  by  injection  or  inunction  rather  than  by  mouth  and  the 
insoluble  salts  are  preferable  to  the  soluble  ones  for  internal 
administration.     A   salicylar senate   of   mercury,   is   highly   ex- 


GENERAL  ANEMIA  429 

tolled  by  French  physicians.  Sodium  cacodylate  is  much  used 
in  this  country.  The  old  Donovan's  solution  of  arsenious 
and  mercuric  iodides,  containing  the  three  antisyphilitic  rem- 
edies, may  be  tried.  Apart  from  the  uncertainty  of  the  action  of 
the  newer  arsenical  remedies  such  as  salvarsan  and  neosalvarsan 
upon  the  senile  organism,  the  aged  will  rarely  permit  a  repetition 
of  their  intramuscular  injection  owing  to  the  pain,  but  an 
intravenous  injection  is  free  from  this  objection.  For  local 
manifestations  of  the  disease,  such  as  syphilitic  ulcers  including 
the  primary  lesion,  bismuth  subnitrate  and  calomel  in  equal 
parts  may  be  used  as  a  dusting  powder.  If  the  chancre  has 
become  phagedenic  it  should  be  cocainized  and  touched  with 
a  drop  of  acid  nitrate  of  mercury  or  of  pure  nitric  acid.  For 
the  enlarged  glands  the  oleate  of  mercury  in  a  5  per  cent, 
ointment  should  be  used.  The  scarlet  red  ointment  is  said  to 
cure  localized  lesions. 

GENERAL  ANEMIA 

The  old  classification  of  anemias  into  primary  or  idiopathic 
and  secondary  or  symptomatic  anemia  is  convenient  rather  than 
correct,  as  it  is  based  upon  etiological  factors,  the  cause  of  some 
being  unknown.  These  are  progressive  pernicious  anemia  and 
chlorosis,  to  which  some  authors  add  leukemia  and  pseudo- 
leukemia. It  is  not  at  all  certain  that  pernicious  anemia  and 
chlorosis  are  not  due  to  bacterial  or  toxic  influences  and  hence 
are  symptomatic  anemias  similar  to  the  anemia  of  cancer  or 
malaria.  Anemia  includes  many  forms  of  blood  changes.  In 
oligemia  the  entire  quantity  of  blood  is  diminished.  In  hydre- 
mia the  proportion  of  water  is  increased  with  the  consequent 
proportionate  diminution  of  the  other  elements.  In  oligocythe- 
mia the  proportion  of  red  cells  is  diminished.  In  hemoglobine- 
mia  the  percentage  of  hemoglobin  in  the  cells  is  reduced.  In 
leukemia  the  white  cells  are  increased.  In  some  forms  of  anemia 
the  albumin  content  is  diminished,  in  other  forms  there  is  a 
change  in  the  character  of  the  cells.  All  forms  of  anemia  except 
chlorosis  are  found  in  the  aged. 

Oligemia. — A  diminution  in  the  total  quantity  of  blood  in 
the  aged  was  noted  by  Geist.  This  is  due  to  the  degeneration 
of  the  hemapoietic  system,  to  contracted  blood-vessels,  obliter- 
ated capillaries  and  diminished  thirst.     The  composition  of  the 


430  PATHOLOGICAL   OLD    AGE 

blood  is  not  altered.  This  oligemia  vera  is  marked  in  poorly 
nourished  individuals  in  whom  there  exists  atrophy  of  all  the 
tissues,  though  the  individual  remains  in  fairly  good  health. 
This  being  a  physiological  condition  in  old  age,  nothing  can  or 
need  be  done  for  it.  Inorganic  salts  of  iron  will  not  increase  the 
hemoglobin  percentage  and  the  increased  ingestion  of  food  and 
drink  will  not  improve  the  degenerated  spleen  or  bone  marrow 
nor  the  capacity  of  the  blood-vessels. 

In  traumatic  oligemia,  the  diminished  amount  of  blood  is 
occasioned  by  hemorrhage.  It  may  be  a  slow  persistent  bleeding 
as  from  hemorrhoids  or  cancer,  or  a  sudden  severe  hemorrhage 
as  when  a  vessel  is  cut.  In  sudden  hemorrhage  there  is  intense 
thirst,  a  physiological  provision  for  replacing  the  lost  fluid. 
The  blood-forming  tissues,  however,  are  degenerated  in  the  aged 
and  repair  proceeds  slowly  if  at  all.  While  in  maturity  the  injec- 
tion of  normal  saline  solution  will  generally  prevent  the  collapse 
following  profuse  hemorrhage,  and  will  sustain  the  patient 
until  the  spleen  and  marrow  have  replaced  the  lost  cells,  the 
aged  frequently  succumb,  unless  transfusion  is  performed.  In 
slow  persistent  hemorrhage  the  cause  must  be  removed  if 
possible  and  nutritious  food  supplied.  Iron  medication  in  the 
aged  is  generally  worthless.  The  inorganic  forms  of  iron  are  not 
readily  assimilated  and  the  organic  preparations  do  not  increase 
the  hemoglobin  percentage  nor  the  number  of  red  cells.  Iron- 
holding  foods  such  as  green  vegetables,  salads,  spinach,  cabbage, 
young  beans,  peas  and  lentils  are  recommended.  Red  bone 
marrow  from  the  long  bones  of  young  animals  will  increase 
the  number  of  red  cells  where  they  are  deficient,  but  the  remedy 
soon  becomes  objectionable  to  the  patient. 

Hydremia. — This  is  the  usual  condition  of  the  blood  when  the 
cells  are  damaged  by  bacterial  or  toxic  influences.  It  may  also 
occur  when  there  has  been  slow  inanition  with  a  large  ingestion 
of  liquids. 

Hydremia  gives  rise  to  local  edemas,  miliary  hemorrhages, 
and  to  irregular  heart  action.  The  treatment  depends  primarily 
upon  the  cause.  For  the  removal  of  the  excessive  amount  of 
fluid,  diuretics  and  diaphoretics  must  be  used,  the  selection  of  the 
drug  depending  upon  the  condition  of  the  heart  and  kidneys. 
The  saline  cathartics,  in  concentrated  solution,  are  often  effec- 
tive in  this  condition. 


OLIGOCYTHEMIA 


431 


Albumin  Deficiency. — Grawitz  has  shown  that  the  anemia 
of  inanition  is  not  due  to  a  deficiency  of  iron  but  to  a  general 
deficiency  of  albumin  with  consequent  deficiency  of  albumin  in 
the  plasma.  As  a  result  of  this  impairment  of  the  plasma  the 
red  cells  degenerate.  Whatever  will  cause  disturbance  in  the 
assimilation  of  albumin  will  produce  this  form  of  anemia,  and  it 
is  therefore  found  most  frequently  in  gastric  atony  and  dyspepsia. 
The  treatment  depends  upon  the  cause. 

Hemoglobinemia. — The  agents  which  destroy  the  red  cells 
first  release  the  hemoglobin,  which  is  then  carried  by  the  serum 
to  be  converted  in  the  liver  and  eliminated  by  the  kidneys  as 
hemoglobin  or  methemoglobin.  As  the  hemoglobin  is  released 
before  the  destruction  of  the  cell  we  find  the  hemoglobin  per- 
centage proportionately  lower  than  the  cell  count.  In  pernicious 
anemia  the  red  cells  though  greatly  diminished  in  number  are 
generally  very  large  and  may  contain  then  as  much  hemoglobin 
as  the  healthy  cells,  consequently  we  get  a  high  color  index  in 
spite  of  a  low  blood  count.  In  those  cases  in  which  there  is 
a  low  hemoglobin  percentage  sterile  iron  by  hypodermic  in 
combination  with  arsenic  may  be  tried  or  it  may  also  be 
given  in  the  form  of  hemoglobin  and  arsenic  while  manganese 
may  be  added.  In  every  case,  however,  it  is  necessary  to  reach 
the  cause  of  the  anemia  and  remove  that  before  we  can  expect 
permanent  results. 

Oligocythemia. — Diminution  of  the  number  of  red  cells  is  al- 
ways found  in  anemia.  In  oligemia  the  proportionis  maintained, 
but  in  every  other  form  the  proportion  is  reduced,  the  lowest 
number  recorded  being  143,000  per  cubic  millimeter,  and  that 
was  in  a  case  of  progressive  pernicious  anemia.  In  anemia  the 
red  cells  degenerate  before  they  are  destroyed  and  they  present 
various  abnormalities  in  size,  shape,  staining  qualities,  hemo- 
globin percentage,  and  the  presence  of  nuclei.  The  principal 
causes  for  anemia  in  the  aged  are  malignant  disease,  malaria  and 
other  infections,  chronic  suppuration,  chronic  dysentery,  chronic 
nephritis,  cirrhosis  of  the  liver,  metallic  poisons,  intestinal  auto- 
intoxication and  intestinal  parasites.  Pernicious  anemia  is 
believed  to  be  due  either  to  a  specific  micro-organism  or  to  an 
autointoxication  of  gastric  or  intestinal  origin. 

The  only  idiopathic,  primary  form  of  anemia  is  oligemia.  All 
other  forms  are  secondary  to  another  disease  or  part  of  a  more 


432 


PATHOLOGICAL    OLD    AGE 


comprehensive  pathological  condition.  It  is  rarely  possible  to 
make  a  diagnosis  of  the  underlying  condition  from  the  count  or 
character  of  the  red  cells  alone,  as  all  the  various  abnormalities 
may  be  found  in  any  of  the  severe  anemias.  Only  in  pernicious 
anemia  must  we  depend  upon  the  blood  count  for  our  final 
diagnosis. 

The  most  marked  symptoms  of  anemia  occur  in  profuse  hem- 
orrhage. These  are  pallor,  vertigo  and  faintness,  prostration, 
palpitation,  blanched  mucous  membranes,  and  cold  perspiration. 
In  the  chronic  anemias  all  these  symptoms,  excepting  the  pallor, 
are  slight  or  absent.  Most  of  the  diseases  associated  with 
anemia,  occurring  in  the  aged,  give  distinctive  symptoms  apart 
from  the  anemia,  and  only  progressive  pernicious  anemia  need 
be  considered  as  a  distinct  disease  in  which  the  blood  changes 
present  the  main  diagnostic  factor.  The  hook  worm  disease, 
uncinariasis,  resembles  pernicious  anemia  inits  symptoms,  but  it 
presents  as  a  diagnostic  sign  the  eggs  or  worms  in  the  feces. 

Pernicious  Anemia ;  Etiology. — The  cause  of  pernicious  anemia 
is  unknown.  Its  course  would  indicate  the  activity  of  bacteria 
or  of  a  bacterial  toxin  though  no  specific  germ  giving  the  dis- 
tinctive symptoms  or  producing  the  marked  changes  in  the  red 
cells  has  been  found.  In  many  cases  there  is  undoubted  intes- 
tinal autointoxication;  in  some  cases  lead  poisoning  and  carbon 
dioxide  poisoning  have  produced  similar  symptoms.  Persistent 
bleeding  from  the  gastrointestinal  tract  may  give  symptoms  of  a 
rapid  progressive  anemia.  Other  possible  causes  that  have  been 
suggested  are  degeneration  of  the  marrow  whereby  regeneration 
of  the  blood  is  interfered  with;  atrophy  of  the  stomach,  this 
condition  being  frequently  found  after  death;  septic  infection, 
septic  lesions  generally  existing  in  the  gastrointestinal  tract, 
embryonic  cells  of  another  species  of  animal,  etc. 

It  seems  probable  that  many  substances  which  find  their  way 
into  the  blood  have  a  deleterious  influence  upon  the  cells  and 
cause  rapid  impairment  and  destruction.  However,  only  a 
single  etiological  factor  in  the  nature  of  a  bacterial  toxin  can 
produce  the  profound  cell  changes  found  in  a  typical  case  of 
pernicious  anemia.  Many  cases  occurring  in  the  aged  give  the 
ordinary  symptoms  of  pernicious  anemia  and  show  a  low  red  cell 
count  without  the  large  number  of  megaloblasts  or  the  extreme 
poikilocytosis  found  in  the  typical  form  of  pernicious  anemia. 


PERNICIOUS  ANEMIA  433 

In  these  cases  the  bone  marrow  is  found  degenerated  and  the 
anemia  is  evidently  due  to  impaired  hemapoietic  activity.  In 
other  cases  the  regulation  of  the  diet  by  the  withdrawal  of  all 
forms  of  animal  albumin  produces  a  rapid  improvement.  In 
some  cases,  however,  there  is  a  rapid  poikilocytosis  with  a  large 
number  of  megaloblasts,  and  the  red  cells  are  diminished  to 
2,000,000  or  less  per  cubic  millimeter,  and  none  of  the  measures 
employed  to  improve  the  digestion,  eliminate  poisons,  control 
internal  bleeding  or  overcome  septic  infection  have  the  slightest 
effect  upon  the  disease. 

Symptoms. — The  most  pronounced  symptom  of  a  typical 
case  is  a  peculiar  pallor,  not  sallowness  as  in  cancer,  but  a  waxy 
yellowish  color.  The  mucous  membranes  are  blanched  and 
there  is  progressive  bodily  weakness  without  emaciation.  The 
muscles  become  flabby,  and  slight  exertion  causes  dyspnea  and 
palpitation  of  the  heart,  with  fatigue  from  which  recuperation 
is  slow.  The  appetite  is  usually  lost  and  in  most  cases  there  are 
gastric  and  intestinal  disturbances.  Heart  action  becomes 
weaker  and  more  rapid,  systolic  murmurs  are  heard  over  the 
mitral  and  aortic  valves  and  blowing  anemic  murmurs  over  the 
aorta  and  sometimes  over  the  carotids. 

Retinal  hemorrhage  and  purpura  are  frequent  and  occasion- 
ally the  symptoms  of  miliary  hemorrhage  in  the  brain  appear. 
In  those  cases  in  which  the  absorption  of  the  products  of  intesti- 
nal putrefaction  is  supposed  to  be  the  cause,  the  urine  contains  a 
large  amount  of  indican  and  small  amounts  of  cadaverin,  and 
other  substances  derived  from  intestinal  decomposition. 

The  blood  in  pernicious  anemia  is  profoundly  altered.  The 
red  blood  cells  are  greatly  diminished  while  the  hemoglobin 
percentage  is  not  proportionately  reduced.  The  cells  are  dis- 
torted in  shape,  there  are  many  megaloblasts  and  a  few  normo- 
blasts while  platelets  are  increased.  The  leucocyte  count  is 
diminished. 

As  a  result  of  the  faulty  nutrition  of  the  tissues  through  the 
impairment  of  the  blood,  fatty  degenerations  occur  most  mark- 
edly in  the  heart  and  involuntary  muscles.  The  diseases  liable 
to  be  mistaken  for  pernicious  anemia  are  Grawitz'  cachexia  and 
cancer.  Grawitz'  cachexia  gives  similar  symptoms,  but  shows 
no  blood  changes.  In  some  forms  of  cancer  the  only  early  symp- 
tom is  the  cachexia.  This  is  associated  with  emaciation,  the 
28 


434 


PATHOLOGICAL   OLD   AGE 


pallor  is  a  sallowness,  there  is  leucocytosis  and  there  is  never  the 
great  reduction  in  number  or  the  profound  changes  in  the  char- 
acter of  the  red  cells  that  we  find  in  pernicious  anemia.  Retinal 
hemorrhage  is  frequent  in  the  latter  disease,  extremely  rare  in 
cancer. 

Pernicious  anemia  is  a  fatal  disease  though  there  are  occa- 
sional remissions  in  the  symptoms  and  occasional  improvement  in 
the  character  of  the  blood.  Cases  due  to  gastrointestinal  dis- 
turbance are  occasionally  cured  but  it  is  doubtful  if  these  were 
cases  of  true  pernicious  anemia. 

Treatment. — If  an  underlying  cause  can  be  found,  that  cause 
must  be  removed  if  possible.  Where  there  has  been  absorption 
of  the  products  of  intestinal  decomposition,  as  evidenced  by  the 
indican  percentage  in  the  urine,  intestinal  antiseptics  and  the 
exclusion  of  animal  albumin  and  other  purin-forming  foods  are 
necessary.  Gastric  digestion  should  be  stimulated  by  lavage, 
pepsin  and  fruit  acids  or  hydrochloric  acid,  and  intestinal  activity 
should  be  increased  by  the  administration  of  pancreatin  and  the 
bile  salts.  The  sulphocarbolates  are  the  preferable  antiseptics 
in  these  cases. 

Little  can  be  done  in  cases  due  to  persistent  internal  hemor- 
rhage. Adrenalin  solution  will  frequently  stop  the  bleeding  but 
is  dangerous  in  old  age  and  may  cause  apoplexy.  The  lime  salts 
increase  the  viscosity  and  coagulability  of  the  blood  and  may 
stop  internal  hemorrhage.  In  many  cases  the  bleeding  comes 
from  a  cancer  and  surgical  measures  may  be  indicated. 

A  pronounced  oligocythemia  without  marked  poikilocytosis 
points  to  degeneration  of  the  blood-forming  tissues.  In  these 
cases  red  bone  marrow  can  be  given,  with  hemoglobin,  arsenic 
and  manganese.  If  these  measures  fail  when  given  internally 
they  should  be  given  hypodermically. 

LEUKEMIA 

Leukemia  presents  no  marked  difference  from  the  same 
disease  of  maturity.  Both  the  myelogenous  and  the  lymphatic 
types  occur  in  the  acute  and  chronic  forms.  The  acute  form, 
which  is  generally  of  the  lymphatic  type,  is  very  rare  in  the  old, 
and  is  usually  fatal  in  from  one  to  four  weeks.  It  resembles  in 
its  course  a  malignant  acute  infectious  disease,  beginning  with 


LEUKEMIA 


435 


high  fever,  followed  by  rapid  enlargement  of  the  spleen  and  usu- 
ally enlargement  of  the  lymphatics  of  the  neck,  axilla,  inguinal 
and  other  regions,  hemorrhages  from  mucous  surfaces,  purpura, 
etc.  The  chronic  form  may  exist  as  a  slowly  progressive 
cachexia  for  months  before  its  nature  is  suspected.  In  some 
cases,  glandular  enlargement  or  abdominal  distention  is  first 
noticed,  in  other  cases  bleeding  from  the  gums  or  other  hemor- 
rhages first  attract  the  attention  of  the  patient.  There  are 
numerous  vague  symptoms  such  as  gastric  and  intestinal  dis- 
turbances, nervous  symptoms,  headache,  vertigo,  irritability,  or 
a  general  malaise  with  a  feeling  of  being  very  ill  indeed  without 
being  able  to  refer  the  sickness  to  any  one  organ  or  tissue.  In  some 
cases,  especially  in  the  aged,  the  symptoms  point  in  many  dif- 
ferent directions  and  it  is  impossible  to  make  a  diagnosis  until 
the  blood  is  examined. 

The  blood  changes  in  leukemia  are  distinctive  and  a  single 
glance  through  the  microscope  will  suffice  to  determine  the  diag- 
nosis. The  leucocytes  in  myelogenous  leukemia  are  increased 
from  ten  to  two  or  three  hundred  times  the  normal  number  and 
many  abnormal  types  appear. 

In  the  lymphatic  type  the  leucocytosis  is  not  as  great,  but 
the  lymphocytes  form  from  75  to  99  per  cent,  of  the  whole  num- 
ber of  white  cells.  In  no  other  disease  is  the  leucocytosis  as 
high,  or  are  so  many  abnormal  cells  found.  A  lymphocytosis 
occurs  in  whooping  cough,  but  here  the  clinical  symptoms  are 
distinctive.  It  also  occurs  in  the  rare  diseases,  myeloma  and 
chloroma  or  green  cancer. 

The  treatment  of  leukemia  is  unsatisfactory.  The  acute 
form  is  generally  fatal  in  a  few  weeks.  The  chronic  form  pre- 
sents occasional  remissions  with  improvement  under  treatment, 
but  relapses  occur  frequently.  The  most  effectual  treatment 
is  by  means  of  the  X-ray  and  this  has  given  even  better  results 
in  the  aged  than  in  younger  individuals.  Of  drugs,  benzol  has 
been  used  of  late  with  remarkable  success,  and  arsenic  has  had 
a  proven  beneficial  effect.  The  latter  is  given  in  the  form  of 
Fowler's  solution,  beginning  with  1  minim  three  times  a  day, 
and  gradually  increasing  the  dose  a  minim  a  day  until  the 
physiological  effects  appear,  when  its  use  must  be  discontinued 
for  a  few  days,  after  which  the  maximum  dose  is  given  continu- 
ously until  the  cumulative  effects  appear  again.     Quinine  and 


436  PATHOLOGICAL    OLD    AGE 

iron,  useful  in  younger  individuals,  have  little  or  no  effect  in 
the  aged. 

PSEUDOLEUKEMIC  DISEASES 

Under  pseudoleukemic  diseases  are  included  two  diametri- 
cally opposite  types,  diseases  resembling  leukemia  clinically 
but  without  the  leucocyte  changes  and  diseases  having  the 
leucocyte  changes  but  not  the  symptoms  of  leukemia.  Multiple 
lymphoma  and  splenomegaly  belong  to  the  first  type,  myeloma 
and  chloroma  to  the  second  type.  Lymphoma  is  seen  occasion- 
ally in  the  aged,  the  others  are  rare  and  when  occurring  they  do 
not  differ  from  the  same  diseases  of  earlier  life. 

Lymphoma  presents  the  clinical  picture  of  a  chronic  leukemia 
in  which  the  enlargement  of  the  lymphatics  is  most  marked. 
There  is  a  slow  progressive  cachexia,  the  spleen  is  enlarged  and 
hemorrhages  from  the  mucous  membranes  as  well  as  purpura 
are  of  frequent  occurrence.  The  glands  of  the  neck,  axilla  and 
inguinal  region  are  most  frequently  affected.  They  enlarge  but 
remain  in  their  capsule  and  do  not  break  down  or  ulcerate. 
Numerous  other  symptoms  referable  to  the  digestive,  nervous 
and  circulatory  systems  may  appear.  Fever  points  to  infection. 
In  making  a  diagnosis  of  this  form  of  pseudoleukemia  it  is  neces- 
sary to  exclude  leukemia  and  tubercular  and  syphilitic  adenitis. 
The  absence  of  leucocytosis  and  of  abnormal  cells  will  exclude 
leukemia.  The  respective  serum  tests  may  be  required  to  elimin- 
ate tuberculosis  and  syphilis  unless  we  can  get  a  clear  history 
of  either.  The  disease  may  run  a  rapid  course,  or  it  may  be 
slowly  progressive,  lasting  for  years  before  the  cachexia  causes 
fatal  exhaustion.  The  treatment  is  mainly  symptomatic, 
although  arsenic  and  the  X-ray  have  sometimes  a  beneficial 
effect,  which  is,  however,  not  lasting. 

RHINITIS 

Acute  rhinitis  has  the  same  etiological  factors  producing 
the  same  condition  in  earlier  life,  and  the  course  of  the  disease 
is  similar.  Owing  to  the  atrophic  condition  of  the  nasal  mucous 
membrane,  the  local  irritation  is  milder,  there  is  less  hypere- 
mia and  not  so  much  mucous  secretion,  but  a  greater  tendency  to 


RHINITIS  437 

involvement  of  the  nasopharynx  and  conjunctivae.  Local  treat- 
ment is  rarely  required  unless  the  secretion  becomes  mucopuru- 
lent, when  mild,  non-irritating  antiseptics  like  boracic  acid, 
thymol,  and  aristol  may  be  employed  by  insufflation,  or  the 
simple  alkaline  antiseptic  lotions  used  as  a  douche.  An  elevation 
of  temperature  with  aching  limbs,  headache,  labial  herpes,  etc., 
indicates  a  bacterial  infection.  This  is  rarely  severe  and  re- 
quires only  rest,  warmth,  and  small  doses  of  quinine  or  aspirin, 
or  a  combination  of  quinine  and  Dover's  powder,  giving  5  grains 
of  each  twice  daily. 

Chronic  rhinitis  occurs  frequently  in  the  aged,  but  the 
symptoms  are  usually  so  mild  that  no  attention  is  paid  to  it. 
It  occurs  in  persons  who  have  frequent  attacks  of  acute  rhinitis 
or  who  are  constantly  exposed  to  irritating  dust  or  vapors  or 
rapid  changes  in  temperature.  When  following  repeated  acute 
attacks,  it  begins  as  an  atrophic  rhinitis,  the  last  attacks  of 
the  acute  disease  having  left  the  mucous  membrane  dry  and 
thin.  When  due  to  constant  irritation  it  begins  as  a  hyper- 
trophic rhinitis,  with  swollen  mucous  membrane  and  increased 
mucous  discharge.  The  discharge  becomes  thicker  and  finally 
forms  crusts,  while  the  membrane  underneath  becomes  thin 
and  anemic.  The  crusts  are  irritating  and  cause  the  patient 
to  remove  them,  thus  leaving  the  underlying  sensitive  membrane 
exposed  to  further  irritation.  In  many  cases  this  leads  to  ulcera- 
tions which  may  extend  to  the  bone  and  cause  necrosis.  There 
in  a  thin  fetid  discharge  from  the  ulcerated  membrane,  the 
fetor  becoming  worse  when  necrosis  of  the  bone  occurs.  This 
fetid  coryza  or  ozena  is  usually  ascribed  to  tuberculosis,  but 
in  the  aged  the  ulceration  and  subsequent  necrosis  of  the  tur- 
binated bones  are  generally  due  to  repeated  irritation  by  the 
patient's  finger  nails.  Owing  to  the  loss  of  the  sense  of  smell 
the  patient  does  not  perceive  the  offensive  odor,  and  this  condi- 
tion may  persist  for  years  before  the  injury  to  the  bone  will 
cause  him  to  seek  relief.  There  is  generally  marked  erosion 
of  the  bones  and  the  nasal  cavity  is  enlarged,  the  nostrils  being 
dilated  by  repeated  stretching  with  the  finger. 

Atrophic  rhinitis  can  be  cured  at  an  early  stage  by  local  medi- 
cation. The  nasal  cavity  should  be  thoroughly  cleansed  with 
an  alkaline  antiseptic  solution,  after  which  anhydrous  lanoline 
should  be  applied,  the  patient  drawing  it  up  as  far  as  possible. 


438  PATHOLOGICAL   OLD    AGE 

This  should  be  done  several  times  a  day  and  continued  for  a  week. 
At  the  end  of  a  week  the  treatment  should  be  omitted  for  a  day 
to  see  if  mucus  still  crusts.  If  this  occurs  the  treatment  should 
be  repeated.  After  necrosis  of  bone  sets  in  surgical  intervention 
becomes  necessary. 

DISEASES  OF  THE  THROAT 

Acute  pharyngitis  is  rather  infrequent  as  the  mucous  mem- 
brane is  usually  atrophied  and  it  requires  a  powerful  stimulus  or 
irritant  to  cause  acute  inflammation.  The  symptoms  are  gen- 
erally mild,  there  being  little  or  no  fever.  The  mucous  mem- 
brane of  the  pharynx  is  not  as  red  nor  as  swollen  as  in  earlier 
life  nor  is  deglutition  greatly  interfered  with.  The  local  symp- 
toms rapidly  subside  upon  spraying  the  throat  with  a  1-10,000 
solution  of  adrenalin  repeated  every  three  hours.  A  tempera- 
ture exceeding  ioo°  in  the  aged  points  to  an  infection  and  the 
mucus  should  be  examined  for  the  spirillae  of  Vincent's  angina 
and  for  staphylococci  and  streptococci. 

Vincent's  angina  is  seldom  found  in  the  aged  and  its  symp- 
toms are  much  milder  than  in  early  life.  The  mucous  mem- 
brane is  covered  with  a  yellowish  or  grayish  exudate  in  which 
the  pathogenic  germs  are  found,  there  is  a  peculiar  fetid  odor  to 
the  breath  and  erosions  and  ulcerations  of  the  mucous  mem- 
brane of  the  mouth  and  throat  occur.  The  constitutional 
symptoms  are  rarely  severe.  Frequent  spraying  with  hydrogen 
peroxide  followed  by  the  application  of  tincture  of  iodine  or  a 
solution  of  iodoform  in  ether  will  generally  cure  this  condition. 

Chronic  pharyngitis  occurs  frequently  in  the  aged  as  a  dry 
atrophic  condition.  It  is  due  to  prolonged  irritation  from  sub- 
stances inhaled  or  taken  in  food.  A  frequent  cause  is  the  in- 
halation of  excessively  dry  warm  air  especially  when  sleeping 
with  the  mouth  open  in  a  room  heated  by  hot  air  radiators.  The 
symptoms  consist  of  a  sense  of  dryness  in  the  throat  that  causes 
persistent  thirst,  and  irritation  produced  by  the  small  amount  of 
tenaceous  mucus  that  is  secreted  and  remains  adherent  to  the 
pharynx,  causing  hawking  and  coughing  in  an  effort  to  dislodge 
it.  In  dealing  with  this  form  of  pharyngitis  we  must  first  dis- 
cover the  cause.  The  atmosphere  of  the  room  can  be  kept  moist 
by  placing  a  vessel  of  water  upon  the  radiators.     To  produce 


DISEASES  OF  THE  THROAT  439 

local  stimulation  a  2  per  cent,  solution  of  menthol  in  a  normal 
saline  solution  should  be  used  as  a  spray.  As  chronic  pharyn- 
gitis is  usually  associated  with  chronic  rhinitis,  the  treatment 
suggested  under  Rhinitis  should  be  combined  with  the  treatment 
of  the  pharyngeal  condition. 

Acute  tonsillitis  is  infrequent  in  the  aged  for  the  same  reason 
that  acute  pharyngitis  is  rarely  met  with.  The  tonsil  itself  is 
usually  atrophied  and  is  rarely  swollen.  The  treatment  sug- 
gested for  acute  pharyngitis  also  applies  to  tonsillitis. 

Retropharyngeal  abscess  is  rare.  When  it  does  occur  the 
etiological  factors,  symptoms  and  treatment  are  the  same  as  in 
maturity.  The  same  also  applies  to  peritonsillar  abscess.  Other 
affections  of  the  throat  such  as  tuberculosis,  syphilis,  and  growths 
are  rare  and  almost  always  secondary.  They  give  no  difficulty 
in  diagnosis,  and  the  treatment  must  be  directed  to  the  primary 
conditions.  Various  neuroses  of  the  throat  may  appear  in  the 
aged,  most  of  them  being  secondary  to  cerebral  or  nervous  dis- 
orders. Their  treatment  involves  the  treatment  of  the  under- 
lying condition. 

Syphilis  may  manifest  itself  in  the  throat  in  the  form  of 
gummata  which  break  down  and  ulcerate.  The  diagnosis  is 
readily  made  by  the  history  and  by  the  presence  of  other  terti- 
ary lesions,  while  the  Wassermann  reaction  is  a  conclusive  test. 
The  usual  antisyphilitic  treatment  is  indicated.  For  local 
treatment  the  ulcerated  surface  should  be  touched  with  a  solu- 
tion of  nitrate  of  silver  or  protargol  or  argyrol.  Primary  and 
secondary  lesions  are  rare. 

Tuberculosis  of  the  throat  appears  as  a  single  or  multiple 
ulcerations  of  the  palate,  pharynx  or  tonsils.  They  spread  slowly 
by  infiltrating  adjoining  tissue  and  do  not  heal  readily.  The 
tuberculin  test  may  be  necessary  to  determine  their  nature. 
Local  treatment  by  the  application  of  silver  or  zinc  salts,  and  the 
constitutional  treatment  for  tuberculosis  is  indicated. 

Growths  of  the  throat  are  very  rare  in  later  life  and  are  almost 
always  secondary.  Little  need  be  said  of  them  as  they  are  purely 
surgical  conditions  and  their  diagnosis  is  simple. 

Neuroses  of  sensation  and  motion  may  occur,  generally  as 
part  of  psychic  and  nervous  disorders,  occasionally  due  to  local 
irritation,  as  from  tobacco,  alcohol,  hot  food,  ice,  etc.  Warm 
emulcent  liquids  may  be  employed  to  relieve  hyperesthesia  and 


44Q 


PATHOLOGICAL   OLD   AGE 


spasm,  and  if  these  fail,  spraying  with  a  2  per  cent,  cocaine 
solution  will  generally  give  temporary  relief.  The  cure  depends 
upon  the  underlying  condition. 

LARYNGEAL  DISEASES 

Acute  laryngitis  may  arise  in  the  aged  from  the  same  causes 
that  produce  the  disease  in  younger  individuals.  The  most 
frequent  cause,  however,  is  spasmodic  cough.  The  senile 
atrophic  mucous  membrane  of  the  larynx  is  not  readily  stimu- 
lated to  acute  inflammatory  activity  and  for  that  reason  acute 
laryngitis  is  not  as  frequent  as  it  is  in  younger  individuals.  The 
disease  is  much  milder,  there  is  rarely  any  elevation  of  tempera- 
ture, the  pain  is  not  severe,  and  the  feeling  of  some  substance 
irritating  the  larynx,  and  inducing  a  cough,  is  not  as  pronounced 
as  in  the  young.  Hoarseness  is,  however,  an  early  and  per- 
sistent symptom  and  may  proceed  to  complete  aphonia.  The 
laryngoscopy  appearance  of  acute  laryngitis  presents  redness 
and  swelling  but  not  as  pronounced  as  in  maturity;  there  is 
little  mucus,  and  little  change  in  the  vocal  cords.  Unless  soon 
relieved  the  disease  becomes  chronic,  or  by  extension  into  the 
trachea  and  bronchial  tubes,  gives  rise  to  a  chronic  bronchitis. 
The  treatment  is  mainly  hygienic,  unless  distressing  symptoms 
appear.  Rest  in  bed,  warmth,  a  clear  dry  atmosphere,  and 
abstaining  from  the  use  of  the  voice  will  generally  effect  a  cure. 
Mild  diaphoretics  may  be  used  and  inhalation  of  a  weak  saline 
solution  is  often  beneficial.  If  there  is  a  persistent  cough  with 
scanty  secretion,  heroin  and  the  syrup  of  senega  may  be  used. 
Hot  and  cold  applications  and  the  applications  of  salt  pork,  etc., 
to  the  neck  are  concessions  to  the  therapy  of  past  ages.  It  is 
doubtful  if  these  have  any  effect  upon  the  disease. 

Acute  submucous  laryngitis  is  an  extension  from  the  mucous 
inflammation.  It  is  very  rare  and  occurs  only  when  a  grave 
acute  laryngitis  has  been  produced  by  a  powerful  irritant  and 
the  irritation  persists.  It  may  lead  to  stenosis  of  the  larynx 
and  necessitate  tracheotomy. 

Perichondritis  occasionally  occurs  in  the  aged,  generally  as  a 
septic  condition  following  infectious  diseases,  local  ulcerations, 
metastatic  abscesses,  etc.  It  occurs  in  two  forms,  perichondritis 
interna  and  externa,  the  former  consisting  of  an  inflammation 
of  the  inner  coat  with  swelling  of  the  mucous  membrane,  the 


LARYNGEAL  DISEASES  44 1 

latter  as  an  inflammation  of  the  outer  coat  with  abscess  forma- 
tion. In  perichondritis  interna  the  symptoms  are  those  of 
acute  laryngitis,  with  progressive  stenosis,  dyspnea  and  hoarse- 
ness leading  to  aphonia.  In  perichondritis  externa  the  early 
symptoms  are  pain  and  fever;  later,  an  abscess  on  the  larynx 
forms,  which  may  break  down  and  cause  constitutional  septic 
symptoms.  As  the  disease  is  almost  always  of  septic  origin, 
serum  therapy  may  be  of  service.  If  this  fails  surgical  inter- 
vention becomes  necessary. 

Edema  of  the  larynx  may  occur  in  the  aged  through  impaired 
circulation  in  cardiac  disease.  It  also  occurs  in  nephritis, 
infectious  diseases,  chronic  laryngitis,  or  as  a  result  of  the  inhala- 
tion of  irritating  vapors,  and  other  traumatic  causes.  It  does 
not  differ  from  the  same  disease  in  earlier  life  and  must  be  treated 
the  same  way.  When  diaphoretics,  diuretics  and  hydragogue 
cathartics  fail,  intubation  or  tracheotomy  must  be  resorted  to. 

Syphilis  of  the  larynx  is  rare  and  the  cases  that  do  occur  are 
almost  without  exception  tertiary  gummata.  If  seen  early 
and  while  the  growths  are  still  small,  they  will  disappear  readily 
under  salvarsan  followed  by  the  mercury  and  iodine  treatment. 
After  they  begin  to  break  down  into  syphilitic  ulcers,  cure  is 
somewhat  more  difficult.  Under  antisyphilitic  treatment  they 
will  gradually  diminish  in  size,  however,  and  disappear,  leaving 
scar  tissue  behind,  which,  upon  contracting,  produces  stenosis. 
In  rare  cases  the  ulcerations  of  the  cartilages  will  cause  destruc- 
tion of  them  and  collapse  of  the  larynx  with  asphyxia. 

Tuberculosis  of  the  larynx  is  very  rare  in  the  aged.  It 
manifests  itself  in  ulcers  which  may  appear  in  any  part  of  the 
larynx.  It  is  often  impossible  to  differentiate  between  a  tuber- 
cular and  a  syphilitic  ulcer.  The  latter  is  usually  clean  looking 
and  not  painful,  while  the  tubercular  ulcer  is  usually  covered  with 
caseous  debris  and  is  painful;  the  syphilitic  ulcer  has  an  exca- 
vated base  with  smooth  everted  edges,  while  in  the  tubercular 
one  the  edges  are  sloping  and  ragged.  These  distinctions,  how- 
ever, are  not  always  well  marked  and  the  differential  diagnosis 
will  then  depend  upon  the  history,  associated  symptoms  and 
signs,  the  result  of  antisyphilitic  treatment,  and  finally,  serum 
tests.  The  treatment  consists  of  cauterization  by  silver  nitrate, 
or  similar  silver  salts,  lactic  acid  or  weak  chromic  acid  solution, 
and  the  application  of  orthoform  in  10  per  cent,  solution  by 


442  PATHOLOGICAL   OLD   AGE 

means  of  a  spray.  The  systemic  treatment  of  the  underlying 
condition  is  necessary. 

Neuroses  of  the  larynx  are  infrequent  and  are  then  almost 
always  associated  with  general  psychic  or  nervous  disturbances. 
Anesthesia  is  not  recognized  unless  a  laryngeal  probe  or  other 
foreign  body  is  introduced,  when  there  will  be  found  an  absence 
of  pain  and  reflex  action.  It  is  extremely  rare,  however. 
Galvanism  is  the  appropriate  remedy. 

Hyperesthesia  sometimes  occurs  in  acute  or  chronic  laryngitis. 
A  slight  irritation,  such  as  a  change  in  the  temperature  of  the 
air,  or  a  dusty  atmosphere,  will  cause  coughing,  while  any  more 
severe  irritation  will  cause  laryngeal  spasm. 

The  irritability  can  usually  be  allayed  by  spraying  the  larynx 
with  a  10  per  cent,  solution  of  orthoform  or  a  2  per  cent,  solution 
of  cocaine.  Spasm  of  the  larynx  may  occur  from  intense  irrita- 
tion, as  from  noxious  vapors,  dust,  sudden  temperature  change 
in  the  inspired  air,  irritation  of  the  vagus  or  of  one  of  its  laryngeal 
branches,  excessive  use  of  the  vocal  cords,  or  in  hysteria  or 
tabes.  The  treatment  depends  upon  the  cause.  A  whiff  of 
chloroform  may  be  required  to  allay  a  spasm.  Laryngeal 
paralysis  occurs  occasionally  in  the  aged.  It  may  be  due  to 
hysteria  or  neurasthenia,  bulbar  paralysis,  various  spinal 
lesions,  compression  of  the  vagus  or  one  of  its  laryngeal  branches 
by  growths,  aneurysm,  glandular  enlargement,  pericarditis, 
infectious  diseases,  poisons,  muscle  or  nerve  degeneration, 
cold,  etc. 

The  symptoms  depend  upon  the  nerve  and  muscles  involved 
and  are  mainly  connected  with  phonation.  These  symptoms 
are  almost  all  due  to  unilateral  or  bilateral  paralysis  of  the  ab- 
ductors, adductors  or  tensors  of  the  vocal  cords.  In  paralysis 
of  those  muscles  that  are  supplied  by  the  recurrent  nerve,  the 
patient  is  voiceless  and  unable  to  cough.  In  paralysis  of  the 
abductors  there  is  dyspnea.  Unilateral  paralysis  of  these  muscles 
is  extremely  rare.  The  adductors  and  tensors  are  usually  para- 
lyzed together.  If  bilateral  there  is  aphonia,  if  unilateral  the 
voice  is  low  and  rough. 

The  treatment  depends  upon  the  causative  condition.  For 
local  treatment  galvanism,  faradization,  and  vibration  are  of 
service.  Inhalation  of  creosote,  menthol  and  ammonia  can  be 
tried.     Local  applications  are  of  doubtful  utility. 


DISEASES  OF  THE  THYROID  GLAND  443 

DISEASES  OF  THE  THYROID  GLAND 

Primary  diseases  of  the  thyroid  are  rare  in  senescence  al- 
though some  authors  regard  the  normal  senile  degeneration  of 
the  thyroid  gland  as  a  form  of  myxedema.  Horsley  indicated 
many  points  of  similarity  between  myxedema  and  the  senile 
cachexia  and  thereon  based  his  conclusion  that  the  senile  cachexia 
depends  upon  the  degeneration  of  the  thyroid  gland — the  more 
slowly  this  gland  degenerates  the  slower  the  process  of  involution 
which  causes  the  senile  cachexia. 

Myxedema  is,  however,  a  pathological  condition  in  which  the 
symptoms  have  but  a  superficial  likeness  to  the  senile  cachexia 
and  it  is  doubtful  whether  the  myxedemic  degeneration  of  the 
gland  is  identical  with  the  senile  degeneration.  The  charac- 
teristic symptoms  of  myxedema  are  swelling  and  infiltration  of 
the  subcutaneous  tissue,  dry  scaly  skin,  general  increase  of  the 
soft  parts,  and  mental  impairment.  The  skin  of  the  face  becomes 
swollen,  especially  about  the  eyes  and  chin,  the  nose  and  mouth 
become  thickened  and  the  face  has  a  dull,  heavy,  expressionless 
appearance.  The  tongue  becomes  thick,  and  is  protruded  with 
difficulty.  The  hands  and  feet  increase  in  size  and  may  lose 
their  contour.  There  is  diminished  surface  sensibility,  all  other 
senses  become  blunted,  the  mind  weakens,  the  will  is  impaired 
and  responses  to  stimuli  are  slowed.  These  symptoms  are  suf- 
ficiently pronounced  to  distinguish  it  from  senile  cachexia. 
The  treatment  consists  of  the  administration  of  thyroid  gland 
or  an  extract  of  it  which  must  be  continued  for  weeks  after  the 
symptoms  have  disappeared  or  until  palpitation  of  the  heart 
announces  that  it  has  exceeded  the  limit  of  its  therapeutic  effect. 
To  prevent  a  relapse  a  dose  should  be  taken  at  regular  intervals. 
Thyroid  extract  has  no  effect  upon  the  senile  cachexia. 

Bronchocele  and  exophthalmic  goiter  are  very  rare  in  the 
aged,  and  they  do  not  differ  from  the  disease  of  earlier  life.  A 
bronchocele  carried  over  from  maturity  may  decrease  in  size  and 
disappear  in  the  process  of  involution  without  treatment. 

Cancer  of  the  thyroid  may  occur  as  a  primary  disease,  giving 
the  usual  symptoms — namely,  rapid  increase  in  size,  cachexia 
and  infiltration  of  neighboring  lymphatics.  Kocher  says  it 
occurs  most  frequently  in  localities  where  goiter  is  endemic  and 
attacks  almost  exclusively  those  in  whom  the  thyroid  is  degen- 
erated.    The  treatment  is  surgical. 


444  PATHOLOGICAL    OLD    AGE 

Tuberculosis  may  occur  as  part  of  a  miliary  tuberculosis  but 
caseous  degeneration  of  the  former  as  well  as  gummous  degen- 
eration of  syphilis  are  very  rare.  Acute  thyroiditis  is  rare  and 
does  not  differ  from  the  disease  in  early  life. 

DISEASES  OF  THE  ADRENALS 

Little  is  known  of  the  diseases  of  these  glands  in  the  aged. 
Addison's  disease  has  been  noted,  but  it  does  not  differ  from  the 
disease  in  earlier  life.  Grawitz  has  described  a  growth  upon  the 
glands,  which  is  occasionally  found  in  old  people  and  which 
begins  as  a  benign  tumor  but  may  become  malignant.  Cancer 
and  other  growths,  such  as  caseous  and  gummous  degenerations, 
have  been  observed  as  secondary  conditions,  but  they  give 
no  distinctive  symptoms  apart  from  the  symptoms  of  the  pri- 
mary disease. 

ACUTE  BRONCHITIS 

Etiology. — Acute  bronchitis  in  old  age  has  a  similar  sympto- 
matology to  the  same  disease  of  earlier  life.  Owing  to  the  atro- 
phy of  the  mucous  membrane  in  the  aged,  a  much  more  powerful 
irritation  is  required  to  cause  an  acute  inflammation  and  there 
is  a  greater  tendency  to  involve  the  finer  tubes  and  to  run  a 
chronic  course.  Great  stress  has  been  laid  upon  the  influence 
of  bacteria  in  the  production  of  acute  bronchitis  and  other  acute 
inflammatory  diseases.  The  senile  organism  is,  however,  more 
or  less  immune  to  bacterial  influences,  and  when  such  infection 
does  occur,  it  is  either  because  the  resistance  had  been  lowered 
through  disease  or  debility,  or  because  the  germs  were  exception- 
ally virulent.  In  either  case  the  disease  is  much  graver  than  in 
earlier  life.  When  the  inflammation  is  due  to  local  irritation, 
and  this  is  generally  the  case,  it  either  subsides  upon  removal  of 
the  irritation,  or  it  becomes  chronic.  Acute  bronchitis  also 
occurs  frequently  as  a  secondary  infection  in  the  course  of  an 
infectious  disease  and  in  these  cases  the  infection  rapidly  in- 
volves the  finer  tubes  and  produces  a  bronchopneumonia. 

Symptoms. — The  symptoms  of  simple  non-infectious  acute 
bronchitis  are  much  milder  than  in  younger  individuals.  There 
is  little  or  no  pain  nor  any  sensation  of  oppression  in  the  chest, 
no  fever,  and  little  irritation,  hence  less  tendency  to  cough. 


ACUTE  BRONCHITIS  445 

The  expectoration  is  scanty,  thick,  not  purulent  and  is  frequently- 
swallowed.  The  physical  signs  are  less  marked.  There  are 
usually  dry  rales,  but  occasionally  moist  rales  and  prolonged 
expiration  are  found.  If  the  capillaries  are  involved,  these 
symptoms  become  aggravated,  and  there  is  a  sense  of  oppression; 
dyspnea  sets  in,  the  cough  is  more  severe,  and  powerful  efforts 
must  be  made  to  loosen  the  tenacious  mucus  in  the  capillaries 
and  to  expel  it.  The  respiratory  murmur  varies,  it  being  weak 
or  lost  over  a  section  in  which  the  bronchial  tubes  are  filled  with 
mucus,  and  distinct  where  the  tubes  are  clear.  Fine  and  coarse, 
dry  and  moist  rales  are  heard,  fine  moist  rales  being  evident 
during  inspiration  over  an  area  in  which  the  capillaries  are 
filled  with  mucus.  Extension  into  the  lung  tissue  may  occur, 
producing  bronchopneumonia.  The  infectious  form  of  acute 
bronchitis  begins  with  fever,  headache  and  malaise.  The  local 
symptoms — cough,  pain  and  expectoration — are  more  marked 
than  in  earlier  life;  the  disease  invades  the  bronchioles  and  finer 
capillaries  and  produces  the  infectious  form  of  bronchopneu- 
monia. An  increase  in  temperature  in  a  non-infectious  case 
points  to  infection. 

Treatment. — Simple  non-infectious  acute  bronchitis  requires 
no  treatment  apart  from  hygienic  measures  and  the  removal 
of  the  cause.  Counter-irritants  like  mustard  or  surface  hyper- 
emia produced  by  dry  cups  over  the  chest,  or  hot  foot  baths, 
will  hasten  recovery.  Of  the  expectorants  the  syrup  of  hypo- 
phosphite  of  ammonia  liquefies  the  mucus,  ipecac  increases  its 
flow,  and  senega  acts  as  an  irritant  to  the  mucous  membrane, 
thereby  increasing  the  tendency  to  cough.  The  narcotics — 
morphine,  codein,  heroin  and  dionin — relieve  the  pain,  but 
dull  the  sensibility  and  lessen  the  irritation,  thereby  preventing 
cough,  which  is  necessary  to  remove  the  accumulated  mucus. 

While  hygienic  measures  are  of  primary  importance  in 
simple  acute  bronchitis,  drug  treatment  is  more  important  in 
the  capillary  form.  The  choice  of  drugs  depends  upon  the 
condition  of  the  mucus  and  upon  the  ability  of  the  patient  to 
expectorate  it.  The  ammonia  salts,  the  carbonate,  chloride 
and  hypophosphite,  liquefy  the  mucus ;  senega  and  apomorphine 
aid  in  its  expectoration.  Apomorphine  cannot  be  used  if  the 
heart  is  weak.  Ipecac,  squills,  and  grindelia,  all  increase  the 
amount  of  mucus  and  should  be  used  whenever  it  is  scanty. 


446  PATHOLOGICAL    OLD    AGE 

Narcotics,  if  required,  should  be  given  in  combination  with 
the  other  drugs.  In  the  infectious  form  the  treatment  of  capil- 
lary bronchitis  should  be  followed.  Frequent  percussion  of  the 
chest  is  necessary  to  recognize  the  presence  of  pneumonia. 
Inhalation  of  creasote,  guaiacol  or  thiocoll  is  beneficial  in  this 
condition.  The  heart  should  be  watched  and  strychnine  given 
if  it  becomes  weak.  Hygienic  regulations  are  rest,  a  dry  equable 
atmosphere  (free  from  dust  and  smoke)  in  a  low  elevation, 
warm  baths,  light  foods,  no  alcoholics  and  no  excitement. 

Fibrinous  bronchitis  is  extremely  rare  in  the  aged.  When 
it  does  occur  it  does  not  differ  from  the  same  disease  of  earlier  life. 

BRONCHIAL  STENOSIS 

Etiology. — The  caliber  of  the  trachea  or  of  a  bronchial  tube 
may  be  diminished  in  the  aged  by  various  conditions  such  as 
pressure  from  without,  a  hyperplasia  of  the  lining  membrane, 
scar  tissue,  a  growth  within,  a  foreign  body  or  muscular  spasm. 
Owing  to  the  multiplicity  of  causes  which  can  produce  stenosis, 
the  disease  is  not  rare.  Stenosis  of  the  trachea  occurs  most 
frequently  where  goiter  is  endemic.  Aspiration  of  foreign 
bodies  such  as  inspissated  mucus  or  food  particles  is  a  frequent 
cause  of  bronchial  stenosis  in  the  aged.  Pressure  from  without 
may  be  caused  by  a  growth,  aneurysm,  enlarged  gland,  or  by 
traumatism.  Inflammatory  swelling  of  the  lining  membrane 
is  rare  and  scar  tissue  and  growths  in  the  trachea  or  bronchus 
are  likewise  very  exceptional.  Spasm  may  occur  in  bronchial 
asthma,  in  hay  fever  and  as  a  result  of  intense  irritation. 

Symptoms. — Difficulty  in  respiration  is  the  most  prominent 
symptom.  This  may  occur  slowly,  rapidly  or  suddenly,  depend- 
ing upon  the  cause.  If  mild,  it  gives  trouble  only  upon  exertion ; 
if  severe  it  produces  a  marked  dyspnea,  and  if  complete  it  causes 
asphyxiation,  depending  upon  the  location  and  extent  of  the 
occlusion.  It  is  often  difficult  to  determine  the  cause  of  dyspnea 
or  the  exact  place  of  the  stenosis.  Sudden  dyspnea  occurs  in 
spasm  and  in  occlusion  caused  by  a  foreign  body.  Dyspnea 
without  cough  occurs  in  compression  stenosis.  In  stenosis  of 
the  trachea  or  bronchial  tube,  however,  the  cause  is  usually 
evident  and  the  location  can  be  determined  thereby.  Upon 
auscultation  there  is  normal  respiration  below  the  point  of 


PERICARDITIS  447 

contraction,  a  whistling  sound  at  the  point,  and  weak,  higher 
pitched  respiratory  sounds  above.  In  stenosis  of  a  fine  tube, 
atelectasis  of  the  part  of  the  lung  supplied  by  the  occluded  tube 
may  occur. 

Treatment. — Treatment  depends  upon  the  cause.  Surgical 
measures  are  generally  required. 

PERICARDITIS 

Acute  pericarditis  is  rare  but  pericardial  adhesions  are  not  in- 
frequent. In  most  cases  these  adhesions  date  from  early  age 
when  the  pericarditis  appeared  as  a  complication  of  or  following 
an  acute  articular  rheumatism  or  some  other  infectious  disease. 
In  some  cases  there  is  a  history  of  cardiac  disease,  in  others  a 
nephritis  was  the  immediate  precursor  of  the  pericarditis.  The 
acute  disease  in  the  aged  does  not  differ  from  the  one  of  earlier 
life.  It  begins  as  an  adhesive  pericarditis  followed  by  a  sero- 
fibrinous exudate.  There  is  dulness  on  percussion,  the  apex  im- 
pulse is  weakened  or  absent,  and  fever,  pain  and  dyspnea  are 
present.  A  friction  sound  over  the  heart,  synchronous  with  the 
heart  contractions  and  not  influenced  by  respiration,  is  path- 
ognomonic of  pericarditis,  but  this  friction  sound  may  be  absent 
in  the  presence  of  an  extensive  exudate.  The  disease  is  more 
serious  in  the  aged  than  in  younger  individuals,  as  it  is  usually 
associated  with  acute  endocarditis  and  myocarditis  arising  from 
the  same  etiological  factors  that  occasion  the  pericarditis.  Re- 
covery from  the  acute  disease  is  rare  and  is  then  always  followed 
by  a  chronic  adhesive  pericarditis  with  obliteration  of  the  peri- 
cardial sac  or  adhesion  to  the  pleura  or  chest  wall.  When  the 
layers  of  the  pericardium  are  adherent  to  each  other  there  may 
be  no  symptoms  at  all  or  only  friction  sounds.  When  the  peri- 
cardium is  adherent  to  the  pleura  or  chest  wall  there  is  displace- 
ment of  the  heart  and  consequent  disturbance  of  its  action. 
Prominent  symptoms  are  a  dimpling  or  retraction  over  the  apex 
beat  at  each  systole,  the  paradoxical  pulse  and  a  diffuse  dias- 
tolic impulse.  The  symptoms  are  more  pronounced  in  adhesion 
to  the  vertebrae.  There  is  then  a  considerable  hypertrophy, 
which  is  generally  followed  by  dilatation  of  the  heart  with  its 
complications. 

The  treatment  of  acute  pericarditis  in  the  aged  comprises 


448  PATHOLOGICAL    OLD    AGE 

rest  and  attention  to  the  symptoms.  The  iodides  may  be  given 
internally  and  a  hyperemia  may  be  produced  over  the  region  of 
the  heart  if  there  is  much  exudation,  and  if  this  fails  it  may  be 
necessary  to  withdraw  the  exudate  through  a  pericardial  canula, 
always  a  dangerous  operation  in  the  aged.  For  a  pericardium 
with  adhesions  to  the  chest  wall,  Brauer  suggested  a  resection  of 
portions  of  the  ribs  with  separation  of  the  adhesions.  Drugs  are 
useless  in  these  cases  except  to  relieve  symptoms  and  to  tempo- 
rarily stimulate  the  heart. 

Chronic  mediastinitis  usually  accompanies  a  chronic  pericar- 
ditis but  it  gives  no  distinctive  symptoms  and  it  is  treated  as 
part  of  the  pericarditis. 

GASTRIC  ULCER 

Gastric  ulcer  is  rare  after  the  sixtieth  year.  In  its  etiology 
and  pathology  it  does  not  differ  from  the  same  disease  of  earlier 
life  but  the  symptoms  in  advanced  age  may  be  modified  by  the 
changes  in  the  stomach  walls. 

Symptoms. — Gastric  ulcers  have  been  found  upon  autopsy 
which  gave  no  symptoms  during  life,  while  in  other  cases  the  first 
indication  of  an  existing  ulcer  was  a  fatal  hemorrhage  or  gas- 
tric perforation.  In  maturity  the  classical  symptoms  are  pain, 
hematemesis  and  hyperchlorhydria.  In  the  aged,  normal  or 
subnormal  acidity  occurs  more  frequently  than  hyperacidity,  the 
pain  is  often  slight  and  may  not  occur  until  two  or  three  hours  or 
more  after  taking  food.  There  is  a  persistent  ache,  however, 
which  only  gives  way  to  the  more  acute  pain  that  follows  the  in- 
gestion of  food.  This  pain  is  rarely  paroxysmal,  but  becomes 
gradually  worse,  until  it  has  reached  its  maximum  intensity,  then 
it  lessens,  leaving  an  ache  which  persists.  The  pain  is  usually 
localized  over  the  site  of  the  lesion,  most  frequently  in  the  me- 
dian line  below  the  sternum. 

The  hematemesis  is  rarely  severe,  yet  it  is  a  grave  symptom. 
The  aged  do  not  vomit  readily  and  when  it  occurs  it  signifies 
a  severe  irritation  or  hemorrhage.  A  severe  gastric  hemorrhage 
may  be  rapidly  fatal  or  cause  a  cachexia  from  which  the  patient 
does  not  recover.  Generally,  there  is  a  slight  regurgitation  of 
food  an  hour  or  two  after  eating,  and  in  the  matter  brought  up 
there  will  be  a  trace  of  blood,  either  as  a  small  black  clot  or  as  a 


GASTRIC  ULCER  449 

particle  of  food  streaked  with  blood.  In  suspected  ulcer  the 
food  thus  brought  up  should  be  carefully  examined  for  this  sign 
of  the  disease.  Blood  can  sometimes  be  found  in  the  feces,  but 
it  is  then  impossible  to  determine  its  exact  source.  The  appe- 
tite is  not  impaired  and  there  may  even  be  a  bulimia.  The  in- 
gestion of  food  generally  gives  temporary  relief  from  pain  but  the 
knowledge  that  the  pain  will  appear  later  produces  a  fear  of  food. 
In  many  cases  there  is  pyrosis,  flatulence,  eructations  of  gas, 
constipation,  etc. 

The  only  diseases  which  may  give  similar  symptoms  are  can- 
cer of  the  stomach,  and  ulcer  of  the  duodenum.  The  pain  of 
cancer  is  not  as  sharp,  but  it  is  more  persistent,  and  occurs 
soon  after  the  ingestion  of  food,  the  hemorrhage  is  darker, 
"coffee  ground  vomit,"  and  there  is  a  pronounced  hypochlor- 
hydria  with  the  presence  of  lactic  acid.  There  is  progressive 
cachexia,  glandular  involvement  and  later  a  tumor  can  be  felt 
at  the  site  of  the  cancer.  In  duodenal  ulcer  the  pain  occurs 
several  hours  after  eating,  and  it  radiates  to  the  back  on  both 
sides  of  the  spine.  Food  and  alkalies  give  relief  from  pain  while 
flatulence  increases  it.  The  tender  point  is  usually  about  the 
umbilicus.  Vomiting  is  rare  and  does  not  give  relief  from  pain. 
Jaundice  is  occasionally  present  and  blood  is  often  found  in  the 
stools. 

Other  diseases  giving  gastric  pain,  like  gastralgia,  the  gastric 
crises  of  tabes,  acute  gastritis,  etc.  have  pathognomonic  symp- 
toms, or  histories,  or  are  not  accompanied  by  hematemesis, 
while  cirrhosis  of  the  liver,  in  which  there  may  be  vomiting  of 
blood,  has  no  gastric  pain.  Erosion  of  the  mucous  membrane 
of  the  stomach,  which  has  been  considered  a  preliminary  stage  of 
gastric  ulcer,  has  not  been  observed  in  the  aged  (Ewald). 

Treatment. — The  treatment  of  gastric  ulcer  does  not  differ 
from  the  treatment  of  this  disease  in  younger  persons.  The 
most  important  indication  is  to  prevent  further  irritation  of  the 
lesion  and  this  can  be  done  only  by  withholding  all  food  as  long 
as  possible  and  resorting  to  rectal  feeding.  This  can  generally 
be  done  for  three  or  four  days,  when  bland  articles  of  diet,  such 
as  calf's-foot  jelly,  oat-meal  gruel,  milk,  and  malted  milk  may 
be  given.  In  the  meantime  bismuth  subnitrate  in  io-grain 
doses  combined  with  an  equal  quantity  of  magnesium  carbonate 

should  be  given  three  or  four  times  a  day.     The  treatment 
29 


4r0  PATHOLOGICAL   OLD   AGE 

should  be  continued  for  a  week  and  afterward  more  substantial 
food  may  be  permitted.  Alcoholics,  spices,  and  acids  must  be 
avoided  and  as  little  salt  as  possible  should  be  taken.  If  the 
pain  is  severe  hypodermics  of  morphine  and  atropia  may  be  used. 
Cocaine  will  allay  the  irritability  which  leads  to  vomiting, 
but  unless  there  is  nausea,  it  should  not  be  used.  Severe  gastric 
hemorrhage  and  perforation  are  almost  invariably  fatal.  If 
hemorrhage  occurs,  tannic  or  gallic  acid  may  be  used  as  astrin- 
gents and  pieces  of  ice  should  be  swallowed.  The  danger  in  these 
cases  is  more  from  shock  than  from  the  amount  of  blood  lost 
and  the  shock  should  receive  attention  as  soon  as  the  patient 
has  received  the  ice  or  the  astringent.  The  most  rapid  and 
effectual  treatment  is  a  hypodermic  injection  of  30  minims  of 
ether.     Surgical  intervention  may  become  necessary. 

DUODENAL  ULCER 

Duodenal  ulcer  is  rare  after  the  sixtieth  year.  Its  etiology 
and  pathology  is  the  same  as  in  younger  individuals. 

Symptoms. — Symptoms  are  generally  vague  and  the  diagno- 
sis must  often  be  determined  by  excluding  gastric  ulcer,  gastric 
cancer,  gall-stone  colic,  intestinal  colic  and  peritonitis.  The 
pain  is  localized  about  the  umbilicus,  and  appears  from  three 
to  four  hours  after  eating.  It  is  relieved  by  food  and  by  alkalies. 
There  may  be  griping  pains,  after  the  pains  produced  by  the 
chyme  and  the  discharge  of  acid  into  the  duodenum  cease. 
Pressure  over  the  site  of  the  ulcer  intensifies  the  pain.  Vomiting 
is  rare,  but  the  feces  generally  contain  a  trace  of  blood.  Flatu- 
lence produces  a  sharp  pain,  jaundice  is  sometimes  present 
and  the  stools  are  then  clay-colored. 

Treatment. — The  treatment  is  as  for  gastric  ulcer,  including 
surgical  intervention,  butpredigested  foods  can  be  given  through- 
out the  disease  and  alkaline  mineral  waters  are  admissible. 

ENTERITIS 

Under  this  name  will  be  described  acute  and  chronic  inflam- 
mations of  the  intestines  including  localized  inflammations 
such  as  colitis,  typhlitis,  proctitis,  etc.  It  is  often  impossible 
to  localize  an  intestinal  inflammation  and  in  many  cases  of 


ACUTE  ENTERITIS  45 1 

enteritis  more  than  one  portion  of  the  bowel  is  involved.  Inflam- 
mation of  the  rectal  wall  can  usually  be  diagnosed  by  inspection; 
inflammation  of  other  portions  of  the  bowels  rarely  give  such 
clearly  defined  symptoms  that  their  exact  location  could  be 
determined.  They  will,  therefore,  all  be  included  under  one 
head,  and  where  localized  inflammations  present  special  symp- 
toms these  will  be  mentioned. 

ACUTE  ENTERITIS 

Etiology. — According  to  Ewald  an  acute  interitis  can  occur 
only  in  the  healthy  senile  individual.  If  there  is  the  ordinary 
senile  degeneration  of  the  intestines  present,  the  acute  inflam- 
mation becomes  converted  into  a  chronic  one  as  soon  as  the  acute 
symptoms  lessen  in  severity. 

The  most  prolific  cause  of  acute  enteritis  in  the  aged  is 
improper  or  excessive  food.  Owing  to  the  lessened  peristaltic 
activity,  food  remains  longer  in  the  bowel  and,  owing  to  the 
diminished  bile  and  intestinal  secretions,  it  decomposes  more 
readily  and  this  decomposing  material  irritates  and  inflames 
the  lining  membrane  of  the  intestines.  The  most  common  food 
articles  that  rapidly  decompose  are  cold  storage  meat  and  eggs 
and  canned  foods,  over-ripe  fruit,  and  tainted  milk.  Certain 
articles  of  food  will  produce  in  some  persons  a  catarrhal  condi- 
tion with  diarrhea,  and  the  change  from  hard  to  soft  drinking 
water  will  often  give  the  same  effect.  The  prolonged  use  of 
drugs,  especially  of  inorganic  salts,  will  cause  an  acute  enteritis, 
although  generally  by  the  time  this  enteritis  is  recognized  it 
has  entered  a  chronic  stage.  A  change  or  deficiency  in  the 
gastric  or  intestinal  secretions  which  permits  undigested  food 
to  pass  into  the  lower  bowel  will  cause  an  enteritis  which  usually 
begins  and  progresses  so  mildly  that  it  becomes  chronic  before 
it  attracts  attention.  Only  a  sudden  and  profound  change  in 
the  secretions  will  produce  an  acute  inflammation  with  acute 
symptoms.  Infection,  the  invasion  of  animal  parasites,  chilling 
of  the  surface  of  the  body  and  nervous  influences,  such  as  shock, 
fear  or  other  strong  emotion,  may  cause  an  acute  catarrhal 
inflammation  of  the  intestines.  An  acute  enteritis  may  be 
secondary  (i)  to  an  inflammation  or  ulceration,  (2)  to  gangrene 
or  cancer  in  an  adjoining  tissue  which  by  extension  has  involved 


452 


PATHOLOGICAL   OLD    AGE 


the  bowel,  (3)  to  an  acute  infectious  disease,  or  (4)  to  local 
circulatory  disturbances. 

Pathology. — Owing  to  the  physiological  senile  degeneration 
of  the  mucous  membrane  of  the  intestinal  tract,  the  inflammatory 
changes  as  found  on  abdominal  section  in  maturity  are  mild  or 
absent  in  senility.  There  may  be  a  slight  hyperemia  and  an 
increased  flow  of  mucus  from  enlarged  mouths  of  mucous  glands, 
more  often  there  are  areas  showing  desquamation  of  epithelial 
cells,  enlarged  follicles,  and  areas  of  ulceration. 

Symptoms. — The  most  prominent  symptoms  of  acute  enteri- 
tis are  pain  and  diarrhea.  The  pain  is  usually  colicky,  coming 
on  spasmodically  and  is  partly  relieved  by  pressure.  An  inflam- 
matory pain,  continuous  and  intensified  by  pressure,  indicates 
an  extension  of  the  inflammation  to  the  peritoneum  or  other 
viscus.  If  the  upper  bowel  is  affected  the  pain  is  more  severe 
and  persistent.  In  inflammation  of  the  jejunum  or  ileum  the 
pain  is  most  severe  at  the  umbilicus.  In  the  lower  bowel  it  is 
rather  a  dull  ache,  rarely  intense  or  paroxysmal,  but  tenesmus 
is  usually  present.  In  proctitis  there  is  always  tenesmus,  a 
burning  sensation  in  the  rectum  and,  if  the  inflammation  is  due 
to  a  foreign  body  or  to  a  hard  mass  of  feces  pressing  against 
the  sphincter,  there  is  a  sharp,  cutting  pain.  In  typhlitis  the 
symptoms  are  referable  to  the  appendix  which  is  usually  in- 
volved also  (see  appendicitis).  In  cases  where  improper  or 
excessive  food  is  the  cause,  the  pain  comes  on  suddenly  two  or 
three  hours  after  the  food  has  been  taken.  When  due  to  a  toxin 
it  may  come  on  in  a  few  minutes  after  ingestion  of  food.  If 
due  to  cold  the  pain  is  usually  mild  and  if  due  to  nervous  influ- 
ence there  is  frequently  entire  absence  of  pain.  Tenesmus  is 
always  due  to  rectal  irritation. 

Diarrhea  is  the  most  distinctive  symptom  of  enteritis,  yet 
it  may  be  absent.  The  stools  are  at  first  soft,  then  watery, 
the  normal  intestinal  contents  being  carried  away  by  the  first 
few  movements.  Much  can  be  learned  from  the  character  of 
these  evacuations.  If  the  early  ones  contain  feces  in  small 
lumps,  the  upper  bowel  is  involved;  if  the  feces  are  formed  then 
the  trouble  lies  in  the  descending  colon  or  rectum.  Mucus 
generally  indicates  inflammation  of  the  large  intestines  though 
minute  particles  may  come  from  the  small  bowel.  Formed 
feces  covered  with  mucus  indicate  proctitis.     Cecal  mucus  is 


ACUTE  ENTERITIS  453 

generally  dark  and  jelly-like,  while  the  color  becomes  lighter 
and  the  consistency  more  fluid  the  nearer  the  inflammation  is 
to  the  anus.  Strips  or  bowel  casts,  indicating  a  mucous  colitis, 
are  rare.  Blood  is  seldom  found  in  the  enteritis  of  the  aged. 
When  it  is  present  it  points  to  a  serious  complication,  or  to 
dysentery.  A  sour-smelling  stool  is  due  to  excessive  carbo- 
hydrate fermentation;  a  foul-smelling  one  indicates  intestinal 
decomposition  or  else  dysentery  or  carcinoma.  Pus  is  found  in 
ulcerative  enteritis.  Food  remnants  appear  in  the  stool  if  the 
duodenum  is  involved.  Yellowish,  greenish,  or  grayish  dejec- 
tions come  from  the  upper  bowel.  In  the  enteritis  due  to  cold 
or  nervous  influences,  the  dejections  are  watery  and  generally 
odorless,  passing  without  pain  or  tenesmus.  In  almost  all 
diarrheas  the  discharges  irritate  the  rectum  and  will  sooner  or 
later  produce  tenesmus. 

In  addition  to  the  pain  and  diarrhea  there  are  generally 
tympanites,  borborygmi,  sometimes  cramps  in  the  muscles  of 
the  abdomen  and  legs,  vomiting  and  intense  thirst  but  no 
elevation  of  temperature  unless  there  is  some  infection.  Vomit- 
ing is  infrequent  in  the  aged.  The  urine  becomes  scanty  and 
high  colored  and  may  contain  a  trace  of  albumin  and  casts. 
If  the  small  intestines  are  affected  there  will  be  an  increase  of 
indican.  The  symptoms  are  usually  more  severe  than  in  earlier 
life,  although  the  alvine  discharges  may  be  reduced  in  quantity 
and  frequency  owing  to  the  atrophy  of  the  lining  mucous  mem- 
brane and  glands.  In  many  cases  of  acute  enteritis  there  is 
rapid  exhaustion  which  may  terminate  in  collapse  and  death. 

Treatment. — The  principal  indications  for  treatment  are 
the  diarrhea  and  pain.  The  measures  for  the  relief  of  the 
diarrhea  depend  in  part  upon  the  location  and  in  part  upon  the 
cause  of  the  enteritis.  In  all  cases  it  is  necessary  to  secure 
thorough  evacuation  of  the  bowel  before  checking  the  diarrhea. 
If  the  inflammation  is  in  the  rectum  this  can  best  be  accom- 
plished by  a  high  enema  using  an  alkaline  solution.  If  in  the 
upper  bowel,  castor  oil  should  be  used,  but  if  this  cannot  be 
taken  another  vegetable  cathartic,  preferably  rhubarb  or 
cascara,  should  be  used.  These  drugs  act  slowly,  evacuation 
following  in  from  twelve  to  twenty  hours.  If  rapid  action  is 
required  we  must  employ  the  saline  cathartics  in  large  doses  and 
given  in  hot  water.     In  many  cases  the  removal  of  offending 


454 


PATHOLOGICAL   OLD    AGE 


material  from  the  bowels  and  rest  will  relieve  the  diarrhea  and 
if  care  is  taken  with  the  diet  for  a  day  or  two  there  will  be  com- 
plete recovery  from  the  enteritis.  If  the  diarrhea  is  due  to  cold, 
the  application  of  moist  heat  will  give  relief,  and  if  due  to  sudden 
emotion  the  relief  of  the  nervous  symptoms  is  generally  all  that 
is  necessary  to  check  it.  When  diarrheal  discharges  continue 
after  the  bowels  have  been  cleared,  they  should  be  checked  by 
the  use  of  astringents,  preferably  bismuth  subnitrate  in  io-grain 
doses.  Opium  in  1/4-grain  doses  should  be  added  if  there  is 
much  pain.  For  the  pain  alone  a  hypodermic  injection  of 
morphine  and  atropine  can  be  used.  For  the  relief  of  tenesmus 
a  suppository  of  extract  of  belladonna  and  opium  gives  relief. 
The  powerful  mineral  astringents,  like  sulphate  of  copper  or 
zinc,  are  rarely  required,  but  if  the  discharges  continue  to  have 
a  foul  odor  the  sulphocarbolate  of  soda  or  zinc  should  be  used. 
All  astringent  drugs  should  be  discontinued  as  soon  as  the 
diarrheal  discharges  cease.  Incidental  symptoms,  such  as 
tympanites,  borborygmi  and  muscle  cramps  pass  away  as  soon 
as  the  bowels  have  been  evacuated.  Thirst  should  be  relieved 
by  ice,  not  by  excessive  draughts  of  water.  The  danger  from 
exhaustion  and  collapse  is  much  greater  than  in  younger  indi- 
viduals. In  these  cases  brandy  acts  well  and  strychnine  should 
be  given  if  the  pulse  becomes  weak. 

During  an  attack  of  acute  enteritis  the  food  should  be  light, 
bland,  fluid  and  preferably  predigested.  Food  liable  to  decom- 
pose or  ferment  in  the  intestines  should  be  prohibited  and  on 
the  first  day  of  an  acute  attack  all  food  should  be  avoided.  After 
the  first  day  small  quantities  of  some  predigested  food  may  be 
given  for  a  day,  after  which  more  substantial  nourishment  can 
be  permitted.  Cold  storage  meat  and  canned  food  should  never 
be  used  in  cases  showing  a  tendency  to  diarrhea  or  flatulence. 
If  the  diarrhea  is  followed  by  constipation,  mild  vegetable 
laxatives  should  be  employed. 

CHRONIC  ENTERITIS 

Etiology. — Chronic  enteritis  in  the  aged  is  usually  secondary 
to  an  acute  attack.  A  slow,  progressive  enteritis  is  produced 
when  undigested  food  passes  into  the  lower  bowel  or  when  there 
is  excessive  intestinal  fermentation   and   decomposition.     The 


CHRONIC  ENTERITIS  455 

prolonged  use  of  inorganic  salts  may  produce  a  slow  progressive 
enteritis.  It  may  also  occur  as  a  secondary  condition  following 
intestinal  ulceration  or  other  lesions,  or  may  be  due  to  chronic 
circulatory  disturbances  or  to  diseases  of  metabolism. 

Pathology. — In  mild  cases  no  changes  can  be  found.  There 
is  usually  some  thickening  of  the  mucous  membrane  with 
erosion  and  pigment  deposits  in  or  around  the  follicles.  Passive 
hyperemia  with  ecchymotic  spots  is  sometimes  found,  and  occa- 
sionally there  are  bands  of  dark  thickened,  or  of  light  atrophied, 
membranes  between  them. 

Symptoms. — The  most  prominent  symptom  of  chronic 
enteritis  is  a  diarrhea  alternating  with  constipation.  In  the 
progressive  form  there  is  a  gradual  increase  in  the  number  and 
fluidity  of  the  stools,  these  occurring  most  frequently  in  the 
morning.  The  character  of  the  stools  is  the  same  as  in  acute 
enteritis  and  there  are  often  the  same  incidental  symptoms,  flat- 
ulence, tympanites,  borborygmi,  and  pain.  The  pain,  however, 
is  usually  slight,  rarely  colicky.  If  ulcerations  are  present  there 
will  be  tenderness  over  the  site  of  the  ulcer  and  pain  on  pressure. 
Localization  of  the  inflammation  is  difficult,  yet  the  determina- 
tion of  its  place  is  necessary  to  secure  a  proper  dietary.  Lien- 
tery  points  to  duodenitis  and  this  diagnosis  is  confirmed  if  there 
is  jaundice  and  pain  at  or  above  the  umbilicus. 

In  inflammation  of  the  ileum  or  jejunum  there  is  also  some 
pain  or  tenderness  about  the  umbilicus  with  occasional  colicky 
pains,  the  stools  are  fluid,  grayish  or  greenish,  and  have  a  sour  or 
foul  odor.  The  pain  comes  on  two  or  three  hours  after  eating. 
A  typhlitis  gives  a  brownish  partly  formed  thick  stool  covered 
with  a  dark  jelly-like  mucus,  pain  is  in  the  right  groin  and  the 
feces  have  the  usual  fecal  odor.  Symptoms  of  appendicitis 
may  be  present.  Colitis  produces  a  large  fairly  formed  stool 
covered  with  a  light  mucus  and  the  pain  comes  on  a  few  minutes 
before  the  stool  is  passed.  The  pain  can  be  more  readily  local- 
ized in  the  ascending,  transverse  or  descending  portion  of  the 
colon  than  in  any  other  part  of  the  bowel. 

Proctitis  has  an  almost  pathognomonic  symptom,  tenesmus, 
with  painful  dejections.  The  stools  are  formed  and  are  covered 
with  mucus.  The  presence  of  pus,  blood,  or  shreds  of  mucus  in 
the  dejections  indicates  an  ulceration,  and  the  location  can 
generally  be  determined  by  the  intense  pain  produced  when 


4^5  PATHOLOGICAL    OLD    AGE 

pressing  upon  it.  It  is  important  to  differentiate  between  syph- 
ilitic, tubercular  and  simple  ulcerative  enteritis,  but  the  former 
two  can  generally  be  diagnosed  by  th  history  and  attending 
symptoms.  Carcinoma  of  the  intestim  s  may  simulate  chronic 
enteritis,  but  the  intense  pain,  presence  of  tumor,  cachexia  and 
involvement  of  other  tissues  will  serve  to  differentiate  it  from  the 

milder  affection. 

Treatment. — The  treatment  is  primarily  dietetic.  The  diar- 
rhea can  in  most  cases  be  temporarily  controlled  by  intestinal 
astringents,  or,  if  the  fault  lies  in  the  rectum  or  colon,  by 
starch  enemata.  The  most  important  point  in  the  treatment  of 
chronic  enteritis  is  to  avoid  the  introduction  of  irritating  sub- 
stances into  the  bowel.  Food  liable  to  ferment  or  decompose, 
strongly  acid  substances,  and  food  containing  much  indigestible 
matter  must  be  avoided.  An  examination  of  the  stools  should 
be  made,  and  if  food  particles  are  found,  such  substances  must  be 
avoided  or  given  in  a  predigested  form.  Especially  objection- 
able on  account  of  their  indigestibility  are  vegetables  containing 
much  cellulose,  meat  containing  much  cartilage,  tendon  or 
connective  tissue,  skin  and  fatty  smoked  meats.  Readily  de- 
composing foods  are  cold  storage  meat  and  eggs,  all  canned  food, 
and  overripe  fruit. 

Medicinal  measures  are  confined  to  intestinal  astringents 
and  antiseptics,  and  for  the  occasional  constipation,  mild 
vegetable  laxatives.  Proctitis  alone  can  be  treated  locally  by 
astringent  lotions  and  enemata  and,  if  there  is  much  pain  or 
tenesmus,  by  cocaine  and  belladonna  suppositories. 

DISEASES  OF  THE  LIVER 

Cirrhosis  of  the  liver  is  infrequent  after  the  sixtieth  year  and 
the  hypertrophic  form  is  extremely  rare  in  advanced  life.  The 
infectious  diseases  play  an  insignificant  r61e  in  the  etiology  of 
cirrhosis  of  the  aged,  and  owing  to  the  natural  atrophy  of  the 
organ,  the  enlargement  in  the  hypertrophic  stage  is  not  marked. 
For  a  similar  reason  the  enlargement  of  the  senile  spleen,  which 
is  a  prominent  symptom  in  earlier  life,  rarely  reaches  the  size 
of  the  normal  organ  in  maturity.  Gastrointestinal  disturbances 
arise  early  and  there  are,  occasionally,  gastric  and  intestinal 
hemorrhages   and   frequently   bleeding    hemorrhoids.     Ascites, 


DISEASES  OF  THE  LIVER  457 

which  occurs  late  in  mat'irity,  occurs  early  in  senility,  but  rarely 
reaches  the  extent  seen  m  earlier  life.  The  general  disturbance 
of  the  circulation  and  i  atrition  causes  a  more  profound  senile 
cachexia,  the  complexion  being  sallow  or  tending  toward  jaun- 
dice with  cyanotic  pate,  tes  about  the  nose  and  cheeks.  There 
are  occasionally  shooting  pains,  and  more  frequently  tenderness 
upon  pressure  over  the  liver.  Cerebral  symptoms  develop  late 
in  the  disease. 

A  positive  early  diagnosis  of  hepatic  cirrhosis  in  the  aged  is 
impossible,  the  early  symptoms  being  usually  referred  to  the 
stomach  and  bowels.  The  history  of  the  prolonged  use  of  al- 
cohol on  an  empty  stomach  is  suggestive,  and  the  enlargement 
of  the  liver  points  to  cirrhosis.  A  definite  diagnosis  can  be  made 
later  when  atrophy  sets  in  and  ascites  and  gastric  or  intestinal 
hemorrhages  occur.  Primary  cancer  of  the  liver  in  an  alcoholic 
subject  may  be  mistaken  for  cirrhosis  in  the  hypertrophic  stage. 
If  nodules  cannot  be  felt  it  may  be  impossible  to  differentiate 
them  until  secondary  symptoms  of  the  cancer,  or  atrophy  and 
ascites  of  cirrhosis,  appear.  Cancer  of  the  liver  progresses  more 
rapidly  than  cirrhosis,  the  cachexia  is  more  marked  and  appears 
earlier,  and  there  is  no  ascites.  Cardiac  disease  and  peritonitis 
often  present  some  of  the  symptoms  of  cirrhosis,  but  they  have 
some  pathognomonic  symptoms  of  their  own.  The  treatment 
of  cirrhosis  of  the  liver  is  unsatisfactory.  Drugs  have  no  effect, 
but  may  relieve  the  associated  symptoms.  A  salt-free  diet  will 
sometimes  retard  the  anasarca  but  where  it  fails,  diuretics,  hy- 
dragogue  cathartics  and  diaphoretics  must  be  used.  The  ques- 
tion of  early  or  late  paracentesis  depends  upon  attending  cir- 
cumstances. Some  authors  suggest  tapping  at  the  earliest 
possible  moment  to  prevent  extreme  distention  and  weakening 
of  the  abdominal  muscles,  others  suggest  that  it  be  deferred 
until  the  dyspnea,  cyanosis  or  pulmonary  edema  endanger  life. 
Diuretics  are  usually  ineffectual  in  extreme  ascites  and  hydra- 
gogue  cathartics  may  cause  exhaustion.  It  seems  best  to  tap 
early  and  reduce  the  edema  by  diuretics,  repeating  the  operation 
whenever  the  abdomen  is  again  distended,  and  not  to  delay  until 
dyspnea  or  cyanosis  make  it  imperative.  A  milk  and  simple 
vegetable  diet,  the  administration  of  simple  bitters  with  the  ad- 
dition of  hydrochloric  acid,  and  but  little  liquid  food  with  the 
exception  of  milk  are  the  principal  dietetic  regulations.     Alcohol 


458 


PATHOLOGICAL   OLD   AGE 


must  be  absolutely  prohibited.  Other  treatment  is  purely- 
symptomatic. 

Hypertrophic  cirrhosis,  Hanoi's  cirrhosis,  is  extremely  rare. 
It  resembles  the  hypertrophic  stage  of  atrophic  cirrhosis,  but 
the  liver  does  not  atrophy,  there  is  no  ascites,  though  there  is 
jaundice  but  without  the  clay-colored  stools  that  occur  in  other 
diseases  that  are  accompanied  by  hepatogenous  jaundice.  The 
disease  is  slowly  progressive  and  incurable.  The  treatment  is 
symptomatic. 

Syphilis  of  the  liver  appears  as  a  tertiary,  diffuse,  inter  stitial 
hepatitis,  or  as  gummata.  In  the  former  case  the  disease  re- 
sembles atrophic  cirrhosis  with  but  slight  ascites,  and  cachexia, 
in  the  latter  case  there  are  growths  upon  the  liver  which  can 
usually  be  felt,  they  may  produce  pressure  symptoms,  but  cach- 
exia is  slight.  In  both  cases  there  are  symptoms  of  tertiary 
syphilis  in  other  tissues.  The  history  and  the  Wassermann  test 
will  determine  the  diagnosis.  The  usual  antisyphilitic  treatment 
is  indicated. 


HYPEREMIA  OF  THE  LIVER 

Active  hyperemia  may  be  physiological,  as  when  occurring 
after  a  full  meal,  or  pathological  when  due  to  infectious  and  toxic 
diseases.  The  later  is  rare  in  the  aged  and  when  it  occurs  it  lasts 
as  long  as  the  underlying  disease  lasts.  There  is  a  sense  of  oppres- 
sion, tenderness  on  pressure,  enlargement  of  the  organ,  some- 
times jaundice  and  diarrhea.  The  treatment  depends  upon  the 
cause.  Small  doses  of  calomel  may  relieve  the  congestion 
temporarily. 

Passive  hyperemia :  Etiology. — This  is  a  common  ailment  in 
the  senile  and  generally  occurs  with  cardiac  dilatation  or  with 
other  cardiac  diseases.  Anything  which  obstructs  the  flow 
through  the  vena  cava  or  hepatic  vein  will  cause  hepatic  venous 
stasis. 

Pathology. — The  liver  passes  through  several  stages  beginning 
with  enlargement  due  to  venous  engorgement,  followed  by 
hyperplasia  of  connective  tissue  and  pigmentation  of  the  cells, 
producing  the  nutmeg  liver,  and  lastly  degeneration  of  the  cells 
and  atrophy,  forming  the  atrophic  nutmeg  liver.     The  disease 


HYPEREMIA  OF  THE  LIVER  459 

producing  no  discomforts  until  a  later  stage,  the  physician  seldom 
sees  the  patient  during  the  first  stage. 

Symptoms. — During  the  early  stages  there  may  be  a  sense  of 
weight  in  the  region  of  the  liver,  tenderness  on  pressure  and  en- 
largement of  the  organ,  but  the  early  symptoms  are  not  well 
marked,  the  liver  being  normally  contracted  in  advanced  life. 
Later  there  is  impairment  of  the  functions  of  the  organ,  exhibited 
in  gastrointestinal  disturbances,  clay-colored  stools,  constipa- 
tion, dark  urine,  sallowness  or  jaundice  and  cachexia  with  mental 
depression.     The  liver  is  diminished  in  size  and  tender. 

Treatment. — The  treatment  depends  upon  the  underlying 
condition.  Calomel,  blue  mass  or  bile  salts  are  indicated  in- 
ternally, and  counter-irritation  externally,  by  sinapisms,  leeches, 
dry  cups,  etc. 

Abscess  of  the  liver  is  rare.  The  solitary  or  tropical  abscess 
is  occasionally  found  in  dwellers  of  warm  countries  and  usually 
follows  amebic  dysentery.  Multiple  or  pyemic  abscesses  occur  in 
pyemia.  Embolic  abscess,  a  solitary  abscess,  is  extremely  rare. 
The  symptoms  are  the  constitutional  symptoms  of  septic 
infection  with  local  symptoms  of  pain,  tenderness,  sometimes 
a  feeling  of  weight  or  dragging  when  lying  on  the  left  side, 
enlargement  of  the  organ,  occasional  digestive  disturbances, 
dyspnea,  cough,  ascites  and  jaundice.  Diagnosis  of  multiple 
abscess  is  often  difficult  as  the  local  symptoms  may  be  mild 
and  escape  notice.  The  disease  may  be  mistaken  for  empyema, 
but  the  latter  disease  has  earlier  symptoms  of  pleurisy. 

Rupture  gives  symptoms  of  shock  and  profound  sepsis. 

Treatment  is  surgical.  Serum  therapy  may  be  tried  for  the 
systemic  disease. 

Fatty  degeneration  may  occur  as  part  of  general  obesity,  as  a 
result  of  alcohol  or  poison,  or  in  the  course  of  some  infec- 
tions, and  in  cachexias.  The  disease  gives  no  distinctive 
symptoms.  The  liver  may  be  enlarged,  but  is  not  nodular  or 
painful  and  there  is  no  jaundice  or  cachexia  unless  these  are 
due  to  a  primary  disease.  The  treatment  depends  upon  the 
underlying  condition. 

Amyloid  degeneration  is  very  rare  in  the  aged.  The  liver 
becomes  greatly  enlarged  and  the  border  can  be  felt  as  a  sharp 
ridge  but  it  gives  no  distinctive  symptoms.  The  treatment 
depends  upon  the  cause. 


460  PATHOLOGICAL   OLD   AGE 

DISEASES  OF  THE  PERITONEUM 

Primary  Acute  Peritonitis. — It  has  been  declared  that  a 
primary  acute  non-infectious  peritonitis  does  not  occur.  Cases 
of  acute  peritonitis  following  traumatism,  however,  do  occur 
without  any  evidence  of  bacterial  action,  though  such  cases 
are  extremely  rare. 

Secondary  acute  peritonitis  may  be  due  to  extension  of  an 
inflammation  from  an  adjoining  tissue,  or  to  a  perforation  into 
the  abdominal  cavity.  This  disease,  which  is  infrequent  in 
the  aged,  does  not  differ  from  the  peritonitis  of  earlier  life  except 
that  the  local  symptoms  are  milder,  and  the  constitutional 
symptoms  are  graver,  while  the  disease  is  almost  invariably 
fatal.  The  exudate  is  fibrinous,  serofibrinous,  hemorrhagic, 
purulent  or  gangrenous.  In  some  cases  there  is  no  pain  except 
upon  motion,  and  cases  are  found  without  elevation  of  tempera- 
ture. In  severe  cases  there  is  complete  anorexia  and  insomnia, 
which  often  cannot  be  relieved  by  drugs. 

In  senile  cases  the  invasion  is  frequently  gradual,  without 
chills,  and  with  but  little  pain,  which,  however,  rapidly  increases 
in  severity,  while  several  days  may  elapse  before  the  abdomen 
becomes  distended.  In  these  cases  the  peritonitis  is  an  exten- 
sion of  an  inflammation  from  a  neighboring  inflamed  tissue. 
Constitutional  symptoms  of  septic  infection  are  present  in 
many  cases.  Peritonitis  is  differentiated  from  intestinal  occlu- 
sion by  the  fever  and  pain  which  are  present  at  the  onset,  while 
in  obstruction  the  pain  appears  later  and  complete  constipation 
is  present  from  the  first.  There  is  besides  generally  a  history 
leading  to  the  production  of  the  disease  which  will  aid  in 
the  diagnosis.  The  disease  is  usually  fatal  in  a  few  days. 
Serum  therapy  may  possibly  hold  a  cure  for  this  as  for  other 
infectious  diseases.  Surgical  measures  have  availed  in  some 
cases  in  earlier  life  and  as  a  last  resort  may  be  tried  in  the  aged. 
The  usual  treatment  with  opium  relieves  the  distress  but  does 
not  cure.  It  is  hardly  necessary  to  mention  the  numerous 
remedies  that  have  been  proposed  for  the  treatment  of  perito~ 
nitis  as  none  are  curative.  In  rare  cases  where  the  peritonitis 
comes  on  slowly  as  a  result  of  an  inflammatory  extension  from 
an  adjoining  organ,  absolute  rest  will  be  followed  by  a  subsidence 
of  the  acute  symptoms  and  the  disease  may  become  chronic. 


CHRONIC  PERITONITIS  46 1 

Chronic  peritonitis  may  follow  an  acute  attack,  or  a  prolonged 
peritoneal  irritation,  such  as  in  ascites,  or  it  may  be  due  to 
tuberculosis  or  cancer.  Occasionally,  after  abdominal  section, 
the  symptoms  of  a  mild  peritonitis  appear,  probably  as  a  result 
of  the  irritation  of  the  peritoneum  during  the  operation. 

The  symptoms  are  the  same  as  those  of  acute  peritonitis 
but  are  less  intense  and  more  prolonged.  The  constitutional 
symptoms  are  mild,  or  absent  or  masked  by  the  more  pronounced 
constitutional  symptoms  of  the  underlying  disease.  The  course 
of  chronic  peritonitis  is  a  slowly  progressive  one  unless  due  to 
cancer  when  the  progress  is  usually  rapid.  The  exudate  may 
form  bands  or  adhesions  and  cause  constriction  or  displacement 
of  organs  and  tissues,  producing  intestinal  obstruction  or  occlu- 
sion, displacement  of  the  ovaries,  uterus,  stomach,  liver,  or 
other  abdominal  organs.  Many  uninterpretable  symptoms 
are  found  upon  autopsy  to  be  due  to  peritoneal  adhesions  with 
consequent  displacement  of  abdominal  organs. 

The  diagnosis  is  generally  based  upon  the  history.  If  there 
is  any  question  between  chronic  peritonitis  and  ascites,  it  will 
be  necessary  to  resort  to  paracentesis  and  consequent  examina- 
tion of  the  exudate.  The  serous  exudate  in  peritonitis  has  a 
high  specific  gravity  (1015-1024,  Ewald)  and  it  has  a  decided 
tendency  to  coagulation  and  production  of  fibrin.  The  serous 
exudate  of  ascites  has  usually  a  specific  gravity  below  1015 
and  may  remain  fluid.  Cysts  are  rare  in  the  aged  and  there  is 
usually  a  localized  swelling  in  a  region  in  which  peritonitis  is 
infrequent.  An  ascites  and  a  peritonitis  may  exist  at  the 
same  time,  the  irritation  produced  by  the  ascites  causing 
peritonitis. 

There  is  no  cure  for  this  condition.  The  symptoms  may  be 
relieved  and  the  fluid  withdrawn,  but  its  withdrawal  increases 
the  danger  from  peritoneal  adhesions.  If  these  adhesions  cause 
intestinal  occlusion,  or  other  grave  symptoms,  operation  may 
be  necessary. 

Ascites  is  a  symptom  of  numerous  pathological  conditions 
which  cause  disturbance  in  the  abdominal  circulation,  or  produce 
a  general  hydremia.  The  most  frequent  of  these  in  old  age 
are  diseases  of  the  heart  and  lungs  which  cause  passive  con- 
gestion of  the  abdominal  vessels,  obstruction  of  the  portal  circu- 
lation, chronic  peritonitis,  nephritis,  cancer,  and  the  pressure  of 


462  PATHOLOGICAL   OLD   AGE 

tumors.     Tubercular,  chylous  and  adipose  ascites  are  extremely- 
rare  in  the  aged. 

The  diagnosis  of  a  collection  of  fluid  in  the  abdominal  cavity- 
ought  to  give  no  difficulty.  Cysts  are  rare  in  the  aged,  and  are 
unilateral  and  localized  in  the  organs  which  contain  them. 
Bladder  distention  has  been  mistaken  for  ascites — an  unpardon- 
able error.  The  treatment  of  ascites  depends  upon  the  cause. 
The  local  treatment  is  by  paracentesis.  This  should  be  done  as 
early  as  possible  and  the  fluid  withdrawn  slowly,  care  being 
taken  to  first  empty  the  bladder.  It  is  often  possible  to  retard 
future  exudation  by  the  use  of  diuretics,  diaphoretics,  and  hy- 
dragogue  cathartics,  the  selection  being  determined  by  the  con- 
dition of  the  heart,  kidneys  and  general  strength  of  the  patient. 


DISEASES  OF  THE  PANCREAS 

Apart  from  cancers  which,  according  to  Ewald,  form  about 
60  per  cent,  of  all  pancreatic  diseases,  the  most  frequent  patho- 
logical condition  of  the  pancreas  found  in  advanced  life  is  the 
chronic  pancreatitis  associated  with  diabetes  mellitus.  In 
this  disease  there  is  a  proliferation  of  the  interstitial  connective 
tissue  and  degeneration  and  atrophy  of  glandular  tissue.  There 
are  no  distinctive  symptoms.  Usually,  however,  we  find 
gastric  and  intestinal  indigestion,  emaciation,  sometimes  jaun- 
dice, epigastric  pain,  lipuria,  glycosuria,  and  fatty  stools.  In 
rare  cases  it  is  possible  to  feel  the  indurated  pancreas,  thereby 
confirming  the  probable  diagnosis.  There  is  no  curative  treat- 
ment for  this  condition.  The  relief  of  symptoms  and  the 
administration  of  diastase,  bile  salts  and  pancreatin  with  all 
starchy  food  is  the  most  that  can  be  done. 

Acute  Pancreatitis. — This  may  occur  as  a  hemorrhagic  or 
suppurative  pancreatitis,  both  exceedingly  fatal  conditions. 
It  begins  with  intense  pain  in  the  region  of  the  pancreas,  vomit- 
ing and  collapse.  The  abdomen  becomes  distended  and  tender 
and  there  is  usually  constipation.  The  sudden  onset  of  the  dis- 
ease without  previous  illness  or  history  distinguishes  it  from  in- 
testinal perforation,  intestinal  obstruction,  perforation  of  a 
peptic  ulcer  and  from  gall-stones.  Death  usually  occurs  in  a 
few  days. 


DISEASES  OF  THE  SPLEEN  463 

DISEASES  OF  THE  SPLEEN 

Primary  diseases  of  the  spleen  are  extremely  rare  and  second- 
ary diseases  are  infrequent.  The  acute  swelling  of  the  spleen 
that  generally  accompanies  inflammatory  and  infectious  dis- 
eases is  not  as  pronounced  as  in  earlier  life  and  can  rarely  be 
diagnosed  as  the  organ  is  physiologically  atrophied  and  even 
marked  enlargement  will  not  reach  the  normal  size  of  maturity. 

The  same  applies  to  the  chronic  enlargement  that  accompanies 
diseases  of  the  liver  and  also  to  local  passive  hyperemia  in  cir- 
culatory disturbance.  Such  swellings  of  the  spleen  produce  no 
symptoms.  The  extreme  swelling  of  splenomegaly  may  cause 
pressure  symptoms  but  this  condition  is  very  rare  in  the  senile. 
Acute  splenitis  occurs  usually  as  part  of  the  systemic  disturbances 
occasioned  by  acute  infectious  diseases;  rarely  as  the  result  of 
trauma  or  of  extension  of  an  inflammation  from  an  adjoining 
viscus.  It  is  generally  accompanied  by  a  perisplenitis  and  is 
then  painful  upon  pressure  over  the  spleen.  The  treatment 
depends  upon  the  underlying  cause.  Local  applications  of  hot 
moist  cloths  will  relieve  the  pain.  Chronic  splenitis  may  follow 
an  acute  splenitis,  while  a  gradual  induration  with  hypertrophy 
may  occur  in  the  course  of  a  chronic  infection  or  disease  of  the 
liver.  In  this,  as  in  all  diseases  of  the  spleen  in  which  this  organ 
is  enlarged,  excepting  splenomegaly,  the  hypertrophy  of  the 
atrophied  gland  rarely  reaches  in  size  the  normal  volume  of  the 
gland  in  maturity.  Consequently  there  are  absent  the  sense  of 
weight  and  oppression  and  the  pressure  symptoms  that  are  char- 
acteristic of  the  enlarged  gland  in  earlier  life.  In  inflammatory 
conditions  the  location  of  pain  may  clear  up  the  diagnosis.  In- 
farction of  the  spleen  may  occur  in  the  aged  but  there  are  no 
distinctive  symptoms.  Abscess  usually  follows  an  infarct  and 
may  give  symptoms  of  a  mild  septic  infection,  the  only  symptom 
indicating  its  location  being  tenderness  upon  pressure  over  the 
organ.  The  treatment  is  surgical.  There  is  no  record  of  the 
result  of  serum  therapy  in  this  condition  although  its  employ- 
ment would  be  in  harmony  with  its  use  in  other  cases  of  septic 
infection. 

Splenoptosis  occurs  frequently  as  part  of  the  general  viscerop- 
tosis of  advanced  life.  It  gives  no  marked  symptoms  and  is 
generally  discovered  accidentally  while  percussing  the  abdomen. 


464  PATHOLOGICAL    OLD    AGE 

The  displacement  is  most  pronounced  in  women  who  were  ac- 
customed to  tight  lacing.  If  the  displacement  produces  much 
discomfort,  it  can  generally  be  relieved  by  a  binder  with  a  pad 
which  will  hold  the  organ  in  place. 

Other  conditions,  such  as  tuberculosis,  syphilis,  growths, 
amyloid  degeneration,  cysts,  etc.,  are  extremely  rare  in  the  aged. 
When  present  they  are  usually  secondary  and  give  no  distinctive 
symptoms  apart  from  the  symptoms  of  the  primary  disease. 

DISEASES  OF  THE  KIDNEYS 

Acute  or  active  hyperemia  of  the  kidneys  is  generally  due  to 
irritation  from  drugs,  while  toxemia  from  infectious  diseases, 
the  most  frequent  cause  in  earlier  life,  is  infrequent  in  the  aged 
and  acute  parenchymatous  nephritis,  in  which  acute  hyperemia 
is  the  initial  condition,  is  extremely  rare.  There  are  no  clearly 
denned  symptoms  of  acute  hyperemia  beyond  a  pain  or  a  dull 
ache  over  the  kidneys  which  is  increased  upon  pressure.  The 
urine  generally  contains  blood  and  albumin  but  no  casts.  The 
diagnosis  must  be  made  from  these  symptoms  and  from  the 
history  of  the  ingestion  or  use  of  irritating  drugs.  The  treat- 
ment demands  the  removal  of  the  causative  irritation,  and  the 
administration  of  large  quantities  of  alkaline  water. 

Chronic  or  passive  hyperemia  occurs  frequently  in  the  aged  as 
a  result  of  impaired  abdominal  circulation  caused  by  disease  of 
the  heart,  lungs,  liver,  or  pressure  from  growths.  Arteriosclero- 
sis may  be  a  causative  factor,  although  the  usual  result  of  this 
condition  is  an  anemia  with  consequent  atrophy,  due  to  mal- 
nutrition. The  kidney  in  passive  hyperemia  is  enlarged, 
congested  and  deep  red  in  color,  darker  in  the  pyramids  than 
in  the  cortex.  There  is  no  marked  increase  in  connective 
tissue  and  no  degeneration  of  the  epithelium  of  the  tubes.  The 
symptoms  are  almost  exclusively  associated  with  functional 
activity,  as  evidenced  by  the  urine.  The  quantity  is  diminished, 
the  specific  gravity  is  increased,  and  may  reach  1030  or  more, 
the  solid  constituents  are  increased,  the  percentage  of  urea 
and  uric  acid  being  high.  There  is  usually  albumin  but  rarely 
blood  or  casts.  The  diagnosis  is  readily  made  from  the  exam- 
ination of  the  urine.  The  treatment  depends  upon  the  cause. 
No  irritant  diuretics  should  be  given. 


UREMIA  465 

Anuria  or  total  suppression  of  urine  may  occur  in  the  course 
of  any  renal  or  infectious  disease,  or  as  the  results  of  traumatism, 
shock  or  occlusion  of  both  ureters.  It  may  arise  suddenly 
as  in  shock,  rapidly  as  in  infectious  disease  or  slowly,  the  amount 
of  urine  decreasing  day  by  day  until  there  is  complete  anuria, 
as  in  chronic  hyperemia.  Unless  speedily  relieved  uremia 
follows  but  recoveries  have  been  recorded  even  after  total 
suppression  lasting  fifteen  days.  Treatment  depends  upon  the 
cause.  In  some  cases  vegetable  diuretics  will  produce  such 
irritation  that  free  diuresis  is  followed  by  complete  suppression. 
In  such  cases  bland  or  lithia  water  may  be  taken  and  at  the 
same  time  hydragogue  cathartics  and  diaphoretics  should  be 
given  to  remove  the  excess  of  fluid.  In  some  cases  hot  baths  or 
the  Turkish  bath  will  stimulate  all  excretory  secretions.  Gen- 
erally vegetable  diuretics  like  uva  ursa,  buchu,  digitalis  or 
juniper  are  required.  If  there  is  edema  or  symptoms  of  ap- 
proaching uremia  a  salt-free  diet  should  be  gradually  instituted 
and  more  powerful  diuretics  such  as  potassium  acetate  or  nitrate, 
and  hydragogue  cathartics  should  be  used. 

Uremia  is  usually  of  the  chronic  type,  is  associated  with 
arteriosclerosis  or  chronic  interstitial  nephritis,  and  is  ac- 
companied by  a  persistent  watery  diarrhea.  The  gradually 
increasing  nervous  and  cerebral  symptoms  ending  in  convulsions 
and  coma,  and  the  diminished  excretion  of  urine  and  solids 
determine  the  diagnosis.  Mild  symptoms  may  persist  for  years, 
with  acute  exacerbations,  during  which  convulsions,  dyspnea, 
Cheyne-Stokes  respiration,  and  coma  may  occur.  Cases  are 
occasionally  met  with  which  give  a  number  of  vague  symptoms, 
such  as  headache,  insomnia,  vertigo,  neuralgic  pains,  increasing 
mental  dulness,  impairment  of  sight,  hearing  and  other  senses, 
various  gastric  and  intestinal  disturbances,  etc.,  and  a  diagnosis 
of  general  arteriosclerosis  is  made  until  a  uremic  coma  suddenly 
discloses  the  underlying  condition.  In  all  such  cases  it  is 
necessary  to  determine  the  amount  and  character  of  the  urine 
for  several  days  in  succession  in  order  to  make  a  correct  diag- 
nosis, yet  this  is  rarely  done.  The  most  important  part  of  the 
treatment  of  chronic  uremia  is  a  salt-free  diet  which  in  the 
aged,  must  be  gradually  introduced.  Diuretics  should  be  used 
to  increase  the  action  of  the  kidneys  and  diaphoretics  and 
saline  cathartics  should  be  given  to  increase  elimination  of 
3° 


466  PATHOLOGICAL   OLD    AGE 

waste.  If  there  is  a  nephritis  present  the  saline  diuretics 
should  be  used  instead  of  the  irritating  vegetable  ones.  The 
oils  and  balsams  are  contraindicated.  Pilocarpine  is  dangerous 
if  the  heart  is  weak.  Narcotics  may  be  required  for  convulsions. 
Albuminuria  in  the  aged  if  not  in  large  amount  and  not  as- 
sociated with  casts  is  generally  of  no  importance  and  indicates 
only  a  senile,  contracted  kidney.  It  is,  however,  necessary 
to  exclude  other  causes  for  albuminuria  which  may  prevail, 
such  as  temporary  irritation  of  the  kidneys  by  drugs  or  toxins, 
febrile  states,  changes  in  the  composition  of  the  blood.  The 
treatment  of  the  albuminuria  due  to  above-mentioned  factors 
depends  upon  the  cause. 

Hematuria  may  be  of  renal,  ureteral,  vesical  or  urethral 
origin.  Renal  hematuria  in  the  aged  is  always  a  grave  symp- 
tom indicating  either  a  profound  change  in  the  blood  or  an  in- 
tense irritation  and  congestion  of  the  kidney.  Ebstein  reported 
a  case  of  an  aged  patient  with  hemorrhagic  infarct  of  the  kidney 
and  hematuria  with  rapid  recovery,  but  such  cases  are  rare. 
The  principal  causes  of  renal  hemorrhage  are  nephritis,  acute 
hyperemia,  calculus,  cancer,  papilloma,  pyelitis,  tuberculosis, 
infarction,  traumatism,  infectious  diseases,  pernicious  anemia, 
leukemia  and  late  cirrhosis  of  the  liver.  Ureteral  hematuria 
is  generally  due  to  impacted  calculus  or  to  the  passage  of  a 
rough-edged  stone.  Vesical  hematuria  is  usually  due  to  vesical 
calculus,  acute  cystitis,  ulcer  or  growth  in  the  bladder.  Hemor- 
hage  from  the  urethra  is  generally  due  to  traumatism  or  en- 
larged prostate.  In  renal  hematuria  the  blood  is  intimately 
mixed  with  the  urine  and  is  smoky ;  in  vesical  hemorrhage  the 
first  part  of  the  urine  voided  is  clear,  in  ureteral  hematuria 
the  blood  appears  in  small  clots,  while  urethral  hemorrhage  pure 
blood  can  be  pressed  out  of  the  urethra. 

Hemoglobinuria  occurs  in  cases  in  which  the  red  blood  cells 
are  destroyed  by  infection,  toxins,  or  drugs,  or  by  diseases  like 
pernicious  anemia,  leukemia,  scurvy,  etc. 

The  urine  in  hemoglobinuria  resembles  the  urine  of  hema- 
turia but  there  are  no  blood  cells  in  the  former. 

Hematuria  and  hemoglobinuria  are  incidental  symptoms 
occurring  in  many  diseases  and  while  not  pathognomonic  of 
any,  they  have  a  corroborative  value  of  the  greatest  importance. 
In   hemoglobinuria   the  kidneys   are   usually   not   affected,   in 


CHRONIC  PARENCHYMATOUS  NEPHRITIS  467 

hematuria  of  renal  origin  the  kidneys  are  usually  diseased  either 
primarily  through  local  irritation  or  secondarily  through  blood 
changes. 

The  treatment  depends  upon  the  cause.  Local  treatment 
is  useless  in  hemoglobinuria  as  the  causes  lie  in  the  blood.  In 
renal  hematuria  benzoate  of  ammonia  in  5 -grain  doses  is  some- 
times of  benefit  when  due  to  infectious  disease,  and  camphor 
in  5 -grain  doses  when  due  to  drug  irritation.  Astringents  are 
of  service  in  vesical  hematuria.  The  underlying  cause  must 
be  treated  in  all  cases. 

Pyuria  occurs  in  all  suppurative  conditions  of  the  urinary 
organs  and  passages.  It  will  also  occur  when  an  abscess  in  an 
adjoining  tissue  breaks  into  a  urinary  passage.  The  most 
frequent  causes  in  the  aged  are  cystic  infection  introduced  by 
the  catheter  and  vesical  and  renal  calculus.  The  recognition 
of  pus  in  the  urine  is  of  importance  in  the  differential  diagnosis 
between  senile  non-infectious  cystitis  and  chronic  infectious 
cystitis.  It  may  also  direct  attention  to  the  location  of  an 
infection  giving  constitutional  symptoms,  but  no  pronounced 
local  ones. 

Other  urinary  abnormalities  are  occasionally  met  with,  but 
they  present  no  marked  difference  in  etiology  or  diagnostic 
value,  from  those  of  earlier  life.  Indican  is  usually  found  in 
larger  quantities  than  in  maturity,  while  the  amount  of  mucus 
and  calcium  salts  is  diminished. 

Acute  nephritis  is  generally  due  to  acute  irritation  by  drugs. 
Scarlet  fever,  diphtheria,  typhoid  fever  and  other  infectious 
diseases  which  are  the  principal  etiological  factors  in  early  life 
are  very  rare  in  the  aged.  Exposure  to  cold  and  wet,  another 
potent  etiological  factor  in  younger  individuals,  is  also  less 
prevalent  in  the  aged.  The  disease  does  not  differ  from  the  acute 
nephritis  in  younger  life  and  requires  the  same  treatment.  It 
occasionally  becomes  chronic. 

Chronic  parenchymatous  nephritis  is  rare  and  when  occur- 
ring follows  the  same  course  and  presents  the  same  symptoms 
as  in  younger  individuals.  It  is,  however,  a  graver  disease  from 
the  onset,  the  symptoms  are  more  pronounced  and  it  passes 
through  the  three  stages  rapidly,  death,  due  to  uremia,  some- 
times occurring  within  a  few  months  after  the  acute  initial 
symptoms  have  appeared.     It  is  rarely  prolonged  beyond  a 


468  PATHOLOGICAL    OLD    AGE 

year.  No  plan  of  treatment  has  been  successful  where  the 
degenerative  changes  due  to  the  active  inflammation  have  been 
added  to  the  senile  degeneration.  The  plan  of  giving  a  salt- 
free  diet  cannot  be  followed  in  the  same  manner  as  in  younger 
individuals,  as  the  sudden  withdrawal  of  salt  causes  anorexia 
and  inanition  with  consequent  rapid  exhaustion.  Salt,  alco- 
holics, coffee,  etc.,  to  which  the  patient  may  have  been  accus- 
tomed for  years,  must  be  withdrawn  gradually.  The  exclusive 
milk  diet  has  the  same  objection  since  large  quantities  must  be 
taken  to  supply  sufficient  nutrition.  Malted  milk  is  a  valuable 
substitute  which  will  not  become  objectionable  too  soon,  and 
will  not  require  such  enormous  quantities  of  fluid  as  ordinary 
milk  does. 

Drug  treatment  is  purely  symptomatic.  Irritant  diuretics 
aggravate  the  condition  of  the  kidneys.  The  best  diuretic  in 
these  cases  is  a  saline,  either  potassium  nitrate,  citrate  or  ace- 
tate or  lithium  citrate.  The  natural  lithia  waters  contain  a  large 
proportion  of  lime,  which  is  contraindicated  in  senile  cases. 
The  general  treatment  suggested  under  chronic  interstitial 
nephritis  will  apply  to  this  disease. 

Pyelitis  is  rare,  most  cases  being  due  to  the  irritation  pro- 
duced by  a  renal  calculus,  followed  by  infection.  Typhoid 
fever,  which  is  a  frequent  cause  of  this  condition,  is  rare  in  the 
aged  and  likewise  tuberculosis  and  cancer  of  the  kidney.  The 
disease  does  not  differ  from  pyelitis  in  earlier  life  and  must  be 
treated  the  same  way. 

Renal  and  perirenal  abscesses  and  cysts  may  occur,  but  the 
causes  are  rare  and  in  their  pathology,  symptomatology  and 
treatment  do  not  differ  from  the  same  diseases  in  maturity. 

MYALGIA 

Myalgia,  or  muscular  rheumatism,  occurs  frequently  both 
in  the  acute  and  the  chronic  forms. 

Etiology. — The  most  frequent  cause  of  myalgia  is  a  sudden 
chilling  of  the  surface  especially  when  it  had  been  overheated. 
It  is  probably  due  to  the  same  toxins  that  produce  fatigue, 
as  it  occurs  most  frequently  in  muscles  which  have  been  sub- 
jectd  to  extraordinary  exercise  or  where,  owing  to  poor  surface 
circulation,  a  sudden  chilling  will  still  further  interfere  with  the 


MYALGIA  469 

circulation  and  prevent  the  removal  of  the  toxins  produced  by- 
muscle  activity.  Myalgia  pectoralis,  pleurodynia,  occurs  fre- 
quently as  the  result  of  hard  coughing  or  sneezing;  myalgia 
lumbalis  or  lumbago  occurs  most  frequently  when  the  surface 
had  been  chilled;  myalgia  cervicalis,  torticollis,  may  be  due  to  a 
draught  or  to  extreme  rotation  of  the  head;  myalgia  capitis, 
cephalodynia  or  rheumatism  of  the  scalp,  is  generally  due  to 
exposure  when  the  scalp  is  warm,  as  for  example  when  a  person 
in  a  heated  room  puts  his  head  out  of  a  window  during  extremely 
cold  weather.  The  dull  ache  of  chronic  or  prolonged  myalgia 
is  identical  with  the  pain  in  muscles  that  have  been  excessively 
exercised  and  the  relief  from  these  pains  is  brought  about  by 
measures  best  calculated  to  promote  local  circulation  which 
would  remove  these  toxins.  There  is  no  evidence  that  the 
disease  is  due  to  a  bacterial  infection,  but  causes  that  interfere 
with  local  circulation  such  as  arteriosclerosis,  or  conditions 
interfering  with  the  ability  of  the  blood  to  carry  away  toxic 
material,  as  in  the  gouty  diathesis,  autointoxication,  etc.,  pre- 
dispose to  it.  There  is  also  probably  a  neuralgia  or  neuritis 
present,  the  initial  symptom  generally  starting  with  a  sharp 
neuralgic  pain  as  in  sciatica  or  in  intercostal  neuralgia,  and 
this  pain  can  be  reproduced  upon  motion. 

Pathology. — No  distinctive  lesions  have  been  found,  the 
usual  anatomical  changes  discoverable  upon  autopsy  in  cases 
where  death  had  occurred  from  some  other  disease  while  a 
patient  had  an  associated  myalgia,  being  due  to  senile  degenera- 
tion of  the  muscles  and  nerves. 

Symptoms. — The  initial  symptom  is  usually  a  sharp  neu- 
ralgic pain  which  is  soon  followed  by  a  persistent  dull  ache 
aggravated  upon  motion.  Some  authors  say  the  pain  is  in- 
creased upon  pressure;  others  say  pressure  lessens  the  pain. 
Steady  pressure  without  motion  during  the  neuralgic  stage 
lessens  the  pain,  but  during  the  later  stage  pressure  increases 
the  ache  while  sudden  motion  will  produce  a  sudden  sharp  pain 
resembling  that  of  neuritis.  The  pain  in  the  muscle  may  ex- 
tend to  the  tendons  and  aponeuroses.  In  some  cases  the  initial 
pain  lasts  but  a  moment  or  may  be  absent  altogether,  in  others 
there  may  be  paroxysmal  attacks  even  without  motion.  The 
dull  myalgic  ache  is  always  present  while  the  sharp  neuralgic 
or  neuritic  pain  is  occasionally  absent.     The  disease  is  usually 


470  PATHOLOGICAL    OLD    AGE 

unilateral,  rarely  extending  beyond  one  muscle  or  group  of 
muscles.  The  affected  part  is  always  held  in  a  position  causing 
the  least  strain  upon  the  affected  muscles,  shielding  them  as 
far  as  possible  from  motion.  While  neuralgia  is  an  important 
element  in  the  diagnosis  and  treatment  of  myalgia,  the  recogni- 
tion of  myositis  is  more  important.  Neuralgia  is  of  short  dura- 
tion; there  is  a  painful  point  along  the  nerve,  while  the  surround- 
ing tissue  is  not  painful.  In  myalgia  there  is  no  painful  point 
unless  the  accompanying  neuralgia  is  persistent  and  severe; 
there  is  local  tenderness,  however,  and  the  disease  is  prolonged. 
There  should  be  no  difficulty  in  differentiating  between  myalgia, 
myositis,  pleurisy,  spondylitis,  costal  caries,  cancer,  renal  cal- 
culi, etc.,  which  all  give  localized  pain.  The  aches  due  to 
senile  waste  of  muscle  are  increased  upon  motion,  but  there  is 
no  pain  when  the  patient  changes  his  position  in  bed. 

Treatment. — The  treatment  of  myalgia  consists  of  rest,  heat 
and  the  avoidance  of  the  cause.  In  pleurodynia  it  may  be  neces- 
sary to  strap  the  affected  side  with  strips  of  adhesive  plaster  to 
secure  the  necessary  rest  for  the  affected  muscles.  Heat  should 
be  applied  in  the  shape  of  hot  poultices,  turpentine  stupes  or 
cataplasms.  An  inunction  of  equal  parts  of  chloral  and  cam- 
phor or  menthol  and  camphor  will  relieve  the  pain  of  the  neu- 
ralgia and  may  relieve  the  myositis.  Extremely  hot  baths,  as 
the  Turkish  or  Russian  baths,  are  dangerous  in  old  age.  If 
the  pain  persists  and  is  severe,  it  may  be  necessary  to  use  hypo- 
dermics of  morphine  and  atropin,  but  other  internal  medication 
is  useless.  The  causative  condition,  if  due  to  gout,  autointoxi- 
cation, or  similar  endogenous  factors,  should  be  treated. 

Myositis,  inflammation  of  muscles,  is  rare.  A  chronic  fibrous 
myositis  may  occur  as  a  manifestation  of  tertiary  syphilis,  while 
acute  primary  myositis  is  believed  to  be  due  to  infection  or 
fatigue  toxins.  The  chronic  form  is  an  interstitial  myositis, 
with  proliferation  of  connective  tissue  and  atrophy  of  the  mus- 
cular fibers,  the  muscle  mass  appearing  in  some  parts  swollen, 
in  other  parts  atrophied,  in  parts  soft,  in  others  firm.  The 
disease  spreads  over  large  areas  or  is  scattered  over  many  mus- 
cles, there  is  a  dull  ache  worse  on  motion  or  pressure  and  some- 
times worse  at  night.  The  symptoms  are  relieved  by  anti- 
syphilitic  treatment.  In  the  acute  form  there  is  rapid  atrophy 
of  the  affected  muscles  partly  through  degeneration  and  partly 


Meniere's  symptom  complex  471 

through  pressure  of  round-celled  proliferation  of  the  connec- 
tive tissue.  There  is  a  gradually  increasing  pain  in  the  muscles 
and  progressive  loss  of  power.  The  affected  muscles  are  at 
first  firm  and  apparently  swollen,  later  they  become  thin  and 
soft.  The  disease  resembles  myalgia,  but  the  increasing  pain, 
atrophy  and  loss  of  power  should  serve  to  distinguish  it  from 
the  other.  In  rare  cases  there  is  fever  and  swelling  and  the 
disease  resembles  acute  articular  rheumatism,  there  is,  however, 
no  pain  in  the  joint  itself,  while  the  muscle  pain  is  constantly 
increasing,  and  muscles  in  other  locations  than  over  joints  are 
also  affected. 

Trichinosis  gives  symptoms  similar  to  acute  primary  myositis. 

Examination  of  the  blood  shows  an  increase  of  eosinophiles, 
but  a  positive  diagnosis  can  be  made  only  by  examining  a 
piece  of  muscle  under  the  microscope.  In  polyneuritis  there  are 
painful  points  or  the  pain  is  along  the  line  of  the  nerve,  the 
surface  is  tender  and  there  is  no  atrophy  of  muscle.  No  treat- 
ment is  known  for  myositis.  The  salicylates  are  of  service 
if  there  is  fever  and  narcotics  may  be  required  for  the  pain. 
The  disease  occasionally  disappears  without  treatment. 

Progressive  muscular  atrophy  is  almost  always  the  spinal 
form,  which  had  been  carried  over  as  a  very  slowly  progressing 
disease  from  maturity;  it  never  originates  in  old  age.  The 
history  and  the  symmetrical  atrophy  without  sensory  dis- 
turbance, diminished  tendon  reflex,  fibrillary  twitching,  and 
absence  of  disturbance  in  organs  of  spinal  origin  distinguish 
it  from  other  diseases  in  which  muscular  atrophy  is  a  prominent 
symptom.  The  disease  is  incurable  and  slowly  progressive, 
and  nothing  is  known  to  retard  it. 

MENIERE'S  SYMPTOM  COMPLEX 

Meniere's  disease  of  the  labyrinth  is  extremely  rare  but  the 
symptom  complex  with  some  modifications  is  of  frequent 
occurrence  in  the  aged.  When  due  to  other  causes  than  disease 
of  the  labyrinth  it  is  known  as  pseudo-meniere's  disease. 

Etiology. — In  a  few  cases  the  symptom  complex  is  due  to 
middle  or  inner  ear  affections.  More  often  it  follows  a  general 
disease  such  as  syphilis,  gout,  diabetes,  leukemia,  general  paresis, 
or  may  follow  injury  to  the  head  or  disease  of  the  nose.     It 


PATHOLOGICAL    OLD    AGE 

472 

may  also  occur  in  hysteria,  neurasthenia  and  psychic  disorders. 
The  most  frequent  cause  is  arteriosclerosis  of  the  vessels  of  the 

ear  or  brain. 

Symptoms.— The  symptom  complex  consists  of  a  paroxysmal 
rotary  vertigo,  generally  so  severe  as  to  produce  momentary 
unconsciousness,  followed  by  headache  and  usually  nausea 
and  vomiting.  Tinnitus  and  difficulty  in  hearing  may  precede 
but  generally  follow  an  attack.  The  vertigo  generally  lasts 
a  few  minutes,  rarely  over  a  quarter  of  an  hour,  but  the  headache 
and  nausea  may  last  for  several  hours,  while  the  tinnitus  and 
deafness  may  be  permanent  but  varying  in  degree.  If  the 
vertigo  is  prolonged,  ataxic  symptoms  appear,  but  these  dis- 
appear as  soon  as  vertigo  passes  away.  The  ear  symptoms  may 
appear  on  one  side  or  on  both  sides.  In  some  cases  there  is  a 
persistent  mild  vertigo  with  sudden  exacerbations,  in  other  cases 
complete  deafness  occurs  and  all  other  symptoms  disappear. 

Treatment. — The  treatment  depends  upon  the  underlying 
condition.  There  is  no  known  cure  for  the  labyrinthine  disease, 
but  the  symptoms  usually  disappear  as  soon  as  complete 
deafness  occurs.  When  due  to  other  causes  the  cure  of  the 
primary  condition  will  relieve  the  symptom  complex.  Large 
doses  of  the  bromides  will  usually  relieve  the  nausea,  headache 
and  other  secondary  reflex  symptoms  following  the  vertigo. 
The  only  relief  of  the  vertigo  is  found  in  the  recumbent  posi- 
tion with  the  head  low. 

OSTEOMALACIA 

Etiology. — Osteomalacia  is  probably  due  to  some  perversion 
in  the  function  of  the  thyroid  gland.  The  relation  of  the 
thyroid  to  metabolism  is  still  somewhat  uncertain  and  there 
seems  to  be  a  tendency  to  ascribe  all  trophic  changes  of  unknown 
origin  to  thyroid  disease.  Osteomalacia  has,  however,  been 
found  most  prevalent  where  goiter  is  endemic,  and  Grajon  states 
that  it  is  frequently  found  in  the  aged  insane. 

Pathology. — The  anatomical  changes  are  a  waste  of  cancel- 
lous structure  and  a  resorption  of  lime  salts,  later  the  harder 
structure  about  the  Haversian  canals  also  soften.  The  perios- 
teum generally  becomes  thin  and  sometimes  separates  from 
the  bone;  in  rare  cases  it  becomes  thicker.  The  medullary  canal 
is  increased  in  diameter  and  the  marrow  is  at  first  red,  later  it 


OSTEOMALACIA  473 

becomes  yellowish  and  gelatinous.     The  most  marked  changes 
are  found  in  the  spinal  column. 

Symptoms. — The  disease  in  the  aged  begins  with  persistent 
slight  aches  and  pains,  generally  in  the  back  and  loins,  sometimes 
in  the  extremities,  and  with  increasing  difficulty  in  motion. 
As  the  disease  progresses  the  pains  become  more  severe  and 
motion  is  thereby  restricted  until  finally  the  patient  is  confined 
to  his  bed  avoiding  the  least  possible  change  of  position.  Owing 
to  the  pain,  the  aged  patient  does  not  walk  or  stand  much  and 
the  deformity  in  the  lower  limbs  does  not  become  as  marked  as 
in  Paget's  disease,  but  as  he  sits  more  there  is  a  greater  curvature 
of  the  spine  consisting  of  both  a  scoliosis  and  a  kyphosis  with 
consequent  malformation  of  the  chest  walls.  This  change  and 
the  compression  of  the  pelvis,  depression  of  the  neck  of  the 
femur  and  curvature  of  the  long  bones  of  the  lower  extremities 
produce  a  marked  diminution  in  a  stature.  In  some  cases 
the  ribs  reach  the  ilia.  The  least  affected  are  the  bones  of  the 
skull.  As  the  disease  advances  mental  depression  ensues,  the 
face  becomes  dull  and  expressionless.  Later  constitutional 
symptoms  will  appear  such  as  anemia,  antointoxication  follow- 
ing constipation  dyspnea  and  cyanosis,  then  cardiac  and 
circulatory  disturbance  with  trophic  disorders  in  all  organs  and 
tissues.  The  diagnosis  is  difficult  at  an  early  stage  of  the 
disease  and  can  only  be  made  by  excluding  chronic  rheumatism, 
gout  and  other  arthritic  diseases,  syphilis,  tumors,  carcinoma, 
various  neuralgias,  tabes  and  other  spinal  affections.  Syphilis 
is  excluded  by  nocturnal  exacerbations  of  pain  by  the  history 
and  by  the  result  of  treatment;  rheumatism  by  its  location  in 
the  joints;  gout  by  the  location  and  character  of  the  pain.  In 
these  and  other  arthritic  diseases  the  impairment  of  motion  is 
due  to  a  stifferning  of  the  joint,  while  in  osteomalacia  impairment 
of  motion  is  due  to  weakening  of  the  bone.  Tumors  give  local- 
ized symptoms  and  cancer  can  usually  be  diagnosed  by  the  his- 
tory, the  presence  of  cancer  in  other  localities  and  the  local 
and  general  symptoms.  The  neuralgias  are  localized  and  the 
pains  are  paroxysmal.  Tabes  has  pathognomonic  symptoms 
and  signs  and  in  other  spinal  diseases  the  pains  are  not  diffuse, 
nor  is  there  bone  tenderness.  Paget's  disease  is  more  localized, 
thse  is  a  hyperplasia  of  bone,  and  pains,  if  present,  are  not 
severe. 


474  PATHOLOGICAL    OLD    AGE 

Treatment. — Phosphorus  is  virtually  a  specific  in  osteo- 
malacia. The  rationale  of  this  treatment  lies  in  the  property 
of  phosphorus  to  combine  with  lime  to  form  phosphate  of  lime 
which  is  deposted  in  the  bones.  The  dose  is  i/ioo  grain  three 
times  a  day.  It  can  also  be  given  in  the  form  of  glycerophosphate 
of  lime,  but  lime  salts  not  in  a  phosphorus  combination  are  not 
taken  up  in  this  disease.  Dietetic  and  hygienic  rules  must  be 
observed.  Sulphur  baths  and  massage  may  be  employed, 
but  exercise  or  any  active  motion  is  prohibited.  Codliver  oil 
has  done  good  in  some  cases. 

Osteomyelitis  is  rare  in  the  aged.  Fatigue  is  believed  to 
be  an  important  etiological  factor  in  senile  cases  and  when  it 
attacks  an  aged  person  it  is  generally  after  excessive  walking, 
when  the  tibia  will  be  found  affected.  In  some  cases  no  cause 
can  be  found.  The  symptoms  are  pronounced,  the  pain  is 
intense  and  increasing  in  severity  and  the  constitutional  symp- 
toms of  infection  are  grave.  In  a  few  cases  mild  symptoms 
prevail  but  the  disease  in  the  aged  is  usually  fatal. 

Treatment  is  the  same  as  in  earlier  life,  but  in  the  grave 
form  operation  alone  offers  any  chance  of  recovery. 

SPINAL  DISEASES 

Acute  myelitis  is  rare  in  the  aged,  the  principal  etiological 
factors,  toxins  and  infectious  diseases  being  of  infrequent 
occurrence.  It  does  not  differ  from  the  acute  myelitis  of 
earlier  life,  presenting  the  same  lesions  and  symptoms.  It 
has  a  greater  tendency  though  to  become  chronic. 

Chronic  myelitis  following  the  acute  attacks  is  of  short 
duration.  In  these  cases  vesical  and  intestinal  paresis  generally 
follow  with  consequent  autointoxications,  sepsis  and  exhaustion. 
This  form  of  chronic  myelitis  differs  from  the  senile  myelitis 
in  which  there  is  a  slow,  progressive,  but  never  complete, 
paraplegia,  and  the  intestines  and  bladder  are  but  slightly  if 
at  all  involved.     Treatment  is  the  same  as  in  earlier  life. 

Compression  myelitis  is  almost  always  due  to  veretbral 
caries  or  carcinoma.  A  very  rare  cause  which  does  not  prevail 
in  earlier  life  is  the  compression  produced  by  a  beady  hardening 
of  the  vertebral  artery  in  arteriosclerosis  of  that  vessel.  The 
symptoms  are  the  same  as  in  maturity  and  depend  upon  the 
location  of  the  lesion.     The  causes  being  persisting  and  in- 


^V^yL/i 


Tremorgraph — Multiple  sclerosis.   (Neustaed- 
ter,  Med.  Record,  July  17,  1909.) 


Tremorgraph — Multiple    sclerosis.       (Neustaedter,     Med. 
Record,  July   17,   1909.) 


Tremorgraph — Dementia  paralytica.      (Neustaedter,   Med.  Record,  July   17, 

1909. ) 


CEREBRAL  DISEASES  475 

creasing  in  force  or  extent,  the  symptoms  also  persist  and 
usually  become  more  intense  or  involve  larger  areas,  and  there 
are  no  remissions.  The  compression  myelitis  due  to  caries  is 
slowly  progressive  and  there  is  a  dull  ache.  When  due  to 
cancer  it  is  rapidly  progressive  with  intense  pain. 

The  treatment  depends  upon  the  cause.  Orthopedic  ap- 
pliances are  indicated  in  cases  of  caries  without  abscess.  Tuber- 
culosis or  syphilis  when  present  must  receive  appropriate  treat- 
ment. Cancer  being  usually  a  secondary  condition  following 
cancer  in  other  tissues,  nothing  can  be  done  except  to  relieve 
the  symptoms.  It  may  be  necessary  to  resort  to  narcotics  in 
such  cases.  Spinal  diseases  generally  are  rare  in  the  aged  and 
many  degenerative  changes  which  in  earlier  life  give  pronounced 
symptoms  are  found  upon  autopsy  of  aged  persons,  to  have 
produced  no  symptoms  of  spinal  affection  during  life.  Clearly 
defined  symptoms  of  tabes  dorsalis,  spastic  spinal  paralysis, 
multiple  sclerosis,  syringomyelis,  etc.,  are  very  rarely  observed 
after  the  sixtieth  year,  while  the  lesions  themselves  are  not  at 
all  infrequent.  The  lesions  of  multiple  sclerosis  of  the  cord  are 
frequently  found  after  death  and  appear  to  be  nothing  more  than 
the  normal  senile  changes.  It  is  only  when  these  degenerative 
changes  occur  as  a  result  of  abnormal  factors,  such  as  syphilis, 
infectious  disease,  growths  or  traumatism  that  they  present 
pronounced  morbid  symptoms.  In  senile  cases  the  symptoms 
are  generally  milder  and  more  prolonged  than  in  maturity  but 
pain  is  more  intense,  while  muscle  rigidity  and  motor  paralysis 
may  proceed  to  complete  loss  of  motor  function. 

Cases  of  spinal  disease  may  be  carried  over  as  chronic  affec- 
tions from  earlier  life  and,  owing  to  more  rest  and  better  hy- 
gienic environment  enjoyed  by  the  aged,  the  symptoms  may 
become  milder.  The  degenerations,  however,  cannot  be  re- 
paired and  are  usually  progressive.  The  treatment  of  spinal 
affections  in  the  aged  is  the  same  as  in  younger  individuals, 
care  being  taken  in  the  selection  of  drugs  to  guard  against 
secondary  effects  upon  the  heart  and  blood-vessels.  This 
applies  with  special  force  to  strychnine. 

CEREBRAL  DISEASES 

Meningitis  is  very  rare  in  the  aged.  Pachymeningitis 
interna  may  occur  in  cerebral  atrophy  but  its  symptoms  are 


476 


PATHOLOGICAL    OLD    AGE 


not  clear.  Paroxysmal  attacks  of  headache,  temporary  at- 
tacks of  hemiplegia,  unilateral  muscle  cramps,  and  tempera- 
mental changes  have  been  found  in  connection  with  it,  but 
there  is  no  pathognomonic  sign  or  symptom  complex. 

Purulent  meningitis  may  occur  with  mastoiditis,  otitis 
media,  erysipelas  and  other  infectious  diseases.  It  begins  with 
malaise,  violent  headache  and  other  cerebral  symptoms  point- 
ing to  meningitis.  Rigidity  of  the  muscles  of  the  neck  and  ex- 
tremities occurs.  The  cranial  nerves  in  the  locality  of  the  inflam- 
mation become  involved  and  the  functions  of  the  parts  supplied 
by  them,  are  impaired.  Kernig's  sign  is  present.  The  reflexes 
are  first  exaggerated,  later  abolished.  The  presence  of  pus  in 
the  cerebrospinal  fluid  confirms  the  diagnosis.  The  ordinary 
treatment  for  meningitis,  rest,  quiet,  ice  bags  to  the  head, 
narcotics,  etc.,  apply  to  this  condition.  Serum  therapy  may 
be  tried.     Lumbar  puncture  gives  temporary  relief. 

Tubercular  meningitis  may  occur  in  connection  with  pulmon- 
ary tuberculosis.  The  symptoms  are  the  same  as  in  purulent 
meningitis  and  the  same  local  treatment  is  indicated.  The 
underlying  disease  needs  attention.  Meningeal  affections  in 
the  aged  are  usually  secondary,  run  a  chronic  course  and  while 
incurable  death  in  most  cases  is  due  to  the  underlying  disease. 

Syphilis  of  the  brain  is  very  rare  after  the  sixtieth  year  and 
unless  there  are  gummata  which  produce  cerebral  compression, 
there  are  no  clearly  defined  symptoms. 

Abscess  of  the  brain  is  generally  due  to  traumatism,  occa- 
sionally to  pyemia,  rarely  to  infectious  peritonitis,  endocarditis 
or  other  infectious  inflammation  or  to  abscess  or  gangrene 
elsewhere.  It  does  not  differ  from  the  same  condition  in  earlier 
life. 


HOME  CARE  OF  THE  AGED 


The  old  man  wants  constant  attention  and  needs  constant 
care.  When  he  begins  to  feel  the  weight  of  his  limbs  and  the 
creaking  of  his  joints,  the  growing  weakness  and  the  loss  of 
virility,  when  he  begins  to  notice  the  hundred  and  one  indica- 
tions that  betoken  the  advancing  years,  his  whole  being  becomes 
wrapt  up  in  himself.  His  thoughts  turn  toward  death  and 
his  one  aim  is  the  preservation  of  life.  From  this  moment  he 
becomes  an  object  for  his  solicitude.  While  the  mind  is  still 
bright  he  notes  the  little  aches  and  pains  that  accompany  old 
age,  and  avoids  every  motion  that  might  aggravate  them, 
thereby  losing  the  benefit  of  exercise.  As  the  sense  of  taste 
diminishes,  he  wants  sharper  and  more  spicy  food  and  with  the 
loss  of  teeth  he  swallows  the  food  in  lumps.  He  avoids  strain- 
ing at  stool  and  becomes  constipated,  the  feces  remaining  in  the 
colonic  pouch.  He  finds  a  little  difficulty  in  voiding  urine  and 
he  defers  the  act  until  the  accumulated  amount  gives  him 
distress  and  in  the  meantime  dilatation  of  the  bladder  is  pro- 
duced or  increased. 

When  the  mind  becomes  impaired  he  neglects  his  person  in 
every  direction  until  he  becomes  obnoxious  to  those  around 
him.  He  cannot  accommodate  himself  to  a  progressive  order 
or  to  modern  ideas,  he  becomes  old  fashioned,  even  queer,  while 
those  nearest  to  him  try  to  humor  his  whims  until  patience  is 
well-nigh  exhausted.  At  the  same  time  he  demands  constant 
attention  and  complains  of  the  slightest  neglect.  The  firm 
insistance  upon  hygienic  measures  for  his  benefit  and  welfare, 
which  necessarily  impose  some  exertion  on  his  part,  is  resented 
as  a  hardship  and  creates  a  dislike  of  those  who  are  most  in- 
terested in  his  welfare.  This  is  the  foundation  of  oikiomania, 
the  morbid  state  in  which  the  natural  love  for  those  entitled  to 
the  love  of  the  individual,  is  turned  to  hatred,  without  reason- 
able cause.  As  this  is  common  among  the  aged  who  live  with 
their  family,  it  is  the  principal  bar  to  the  successful  treatment  of 

477 


478 


HYGIENE    IN    OLD    AGE 


diseases  and  the  proper  hygienic  care  of  the  aged  at  home. 
Rather  than  force  the  old  man  to  take  proper  care  of  himself, 
and  thereby  incur  his  displeasure,  they  submit  to  his  whims  and 
permit  him  to  deteriorate  mentally  and  physically  faster  than 
he  would  under  other  circumstances. 

In  many  cases  it  is  possible  to  overcome  the  prejudices  of 
the  aged  by  tact,  and  to  create  in  them  a  sense  of  well-being.  In 
the  article  on  Senile  Cachexia  it  was  pointed  out  that  many 
cases  of  decrepitude  were  really  cases  of  pseudo-  or  psychic 
debility  and  that  the  removal  of  certain  factors  causing  this 
pseudo-debility  would  rejuvenate  the  aged. 

Mental  stimulation  is  the  most  important  measure  in  the 
hygiene  of  the  aged.  Anything  which  will  tend  to  make  the 
senescent  take  an  interest  in  life  beyond  their  own  little  ego 
will  benefit  them.  We  may  repeat  here  that  the  psychic  in- 
fluence of  flattery  is  more  potent  in  arousing  ambition  than 
drugs  or  reasoning.  It  will  arouse  renewed  pride  in  appearance 
which  is  usually  lost  when  ambition  is  lost  in  the  contemplation 
of  death  in  the  near  future. 

Just  as  long  as  this  pride  in  appearance  is  maintained,  so 
long  will  the  individual  follow  willingly  the  hygienic  rules  neces- 
sary for  his  welfare,  even  though  it  requires  some  exertion  and 
effort  to  carry  them  out.  Mental  activity  arouses  physical 
activity  and  creates  vigor  if  the  organism  is  still  in  the  condition 
to  respond.  The  most  powerful  of  the  mental  stimulants  are, 
change  of  scene  and  residence,  change  in  the  mode  of  living,  a 
young  wife  or  husband,  discussion  upon  some  familiar  favorite 
subject,  or  a  hobby.  The  joke  about  the  bald  heads  in  the 
theater  where  there  are  pretty  chorus  girls  has  a  psychological 
basis.  Mental  activity  is  aroused  and  the  old  man  feels  young 
again.  Whatever  the  means  may  be,  the  end  to  be  attained  is 
the  same,  therefore,  mental  activity  must  be  encouraged,  and 
pride  in  personal  appearance  stimulated.  If  this  much  is  ac- 
complished there  will  be  little  difficulty  in  dealing  with  the  old. 

The  other  principal  hygienic  measures  are  food  and  exercise. 
Cleanliness  and  clothing  are  secondary,  for  notwithstanding  the 
importance  of  cleanliness  from  an  esthetic  point  of  view,  many 
reach  advanced  old  age  who  have  rarely  taken  a  bath  and  who 
have  had  little  choice  in  the  selection  of  clothing.  Fresh  air  is 
necessary  and  the  air  of  the  country  is  better  than  the  air  of  the 


HOME  CARE  OF  THE  AGED  479 

city.  Caution  as  to  the  evacuations  seems  superfluous,  as  this 
applies  to  all  ages  and  to  all  conditions.  Still  the  aged  pay  less 
attention  to  the  stools  and  urine,  especially  if  there  is  any  diffi- 
culty in  passing  either,  and  this  neglect  causes  pathological  con- 
ditions. They  should  go  to  the  toilet  at  the  same  hour  each 
day  and  the  family  should  not  place  too  much  reliance  upon 
the  patient's  assurance  that  it  is  "all  right."  The  family 
should  attend  to  the  cleansing  of  the  catheter  and  the  rectal 
tube  if  these  are  used,  and  they  should  be  made  sterile  again 
just  before  they  are  to  be  employed.  A  daily  bath  entails  too 
much  exertion  for  the  old  man  who  has  no  attendant  to  help 
him  in  and  out  of  the  tub.  A  tepid  bath  once  a  week  will 
accomplish  all  that  is  necessary  in  the  case  of  the  aged,  but 
daily  ablutions  of  the  hands,  face  and  neck  should  be  insisted 
upon.  The  common  laundry  soap  should  not  be  used  as  it 
makes  the  skin  excessively  dry.  Either  a  mild  soap  like  castile 
soap  or  plain  borax  can  be  employed,  and  sea  salt  or  common 
salt  should  be  used  for  the  bath.  For  the  bromidrosis,  washing 
with  Florida  water  or  cologne  water  and  powdering  the  part 
with  a  mixture  of  stearate  of  zinc  and  salicylic  acid  will  gener- 
ally relieve,  and  may  cure,  this  condition.  As  the  surface 
temperature  of  the  body  is  generally  low  and  the  aged  do  not 
perspire  readily  they  should  wear  warm  woolens  all  the  year 
round.  In  winter  heavy  underwear  will  keep  them  warmer 
than  a  heavy  overcoat  and  there  is  less  weight  to  carry.  The 
legs  and  feet  should  be  especially  looked  after  as  the  lessened 
surface  sensibility  makes  the  aged  less  sensitive  to  temperature 
changes,  while  the  poorer  surface  circulation  in  the  lower  limbs 
makes  them  especially  liable  to  chilblains,  frost  bites  and 
frozen  feet  and  toes.  This  is  a  frequent  cause  of  senile  gangrene. 
The  same  precaution  need  not  be  taken  with  the  face  but  in 
very  cold  weather  the  ears  should  be  protected.  An  important 
article  of  wear  is  the  shoe,  which  should  be  selected  with  due 
regard  for  corns,  bunions,  hammer-toes  and  broken-down 
arches.  It  should  have  rubber  heels  and  arch  supporters 
whether  there  are  broken-down  arches  or  not.  Apparently 
insignificant,  yet  really  of  great  importance,  is  the  cane,  upon 
which  the  old  man  depends  for  support  when  the  senile  kypho- 
sis and  waste  of  the  muscles  of  the  back  make  him  stoop.  With 
the  cane  he  is  able  to  maintain  a  fairly  erect  position  and  if  he 


480  HYGIENE    IN    OLD    AGE 

uses  it  as  soon  as  he  begins  to  notice  the  tendency  to  stoop  01 
to  fall  into  the  attitude  of  the  senile  slouch,  he  will  keep  erect 
and  lessen  the  strain  upon  the  back  muscles  and  the  compres- 
sion of  the  intervertebral  discs.  The  cane  should  be  sufficiently 
long  so  that  when  the  point  is  on  the  ground  at  the  distance  of 
the  ordinary  step  from  the  body,  the  user  will  not  be  obliged  to 
stoop  over  when  grasping  the  handle.  Most  canes  are  too 
short  and  the  man  must  do  the  very  thing  the  cane  is  intended 
to  prevent. 

The  diet  of  the  aged  must  be  regulated  by  the  state  of  the 
teeth,  stomach  and  intestines,  and  by  the  metabolic  activity 
and  assimilation.  The  senile  organism  requires  less  food,  it 
can  dispose  of  less  food,  and  less  is  assimilated.  Owing  to  the 
changes  in  the  stomach,  digestion  is  slower  and  weaker.  With 
bad  teeth  the  food  is  not  properly  masticated,  consequently  it 
is  swallowed  in  lumps,  which  are  digested  with  difficulty  or  not 
at  all.  Prosthesis  can  remedy  this  defect,  and  here  again  it  is 
often  necessary  to  play  upon  his  pride  in  appearance  to  induce 
him  to  undergo  the  annoyance  and  sometimes  positive  distress 
connected  with  the  making  and  wearing  of  artificial  teeth. 
Women  submit  to  these  discomforts  more  readily  than  men,  for 
their  natural  vanity  induces  them  to  appear  attractive,  even 
when  extremely  old.  Gourmands  who  are  accustomed  to  eat 
too  much  will  not  break  themselves  of  the  habit  when  they 
become  old  unless  gastritis  and  diarrhea  make  a  limited  diet 
imperative.  The  oft-repeated  advice  that  the  aged  should  eat 
little  and  often  is  irrational,  for  digestion  is  naturally  slower 
in  old  age  and  frequent  feedings  keep  the  stomach  constantly 
at  work,  there  being  always  a  mass  of  food  in  the  stomach  in 
different  stages  of  digestion.  This  is  the  most  frequent  cause 
of  flatulence,  heart  burn  and  senile  gastric  catarrh  with  its 
attendant  pyrosis  and  gastrodynia. 

In  old  age,  food  should  be  taken  not  oftener  than  once  in 
five-  or  six-hour  intervals  at  fixed  hours  each  day.  The  number 
of  meals,  like  the  time  of  day  when  the  principal  meal  is  taken, 
is  a  matter  of  habit,  often  of  nationality,  and  does  not  affect 
the  rule.  A  few  simple  directions  will  serve  better  than  any 
fixed  diet  list. 

If  food  cannot  be  masticated  it  should  be  chopped  up  fine 
or  administered  in  the  form  of  mush.     No  food  should  be  taken 


HOME  CARE  OF  THE  AGED  48 1 

between  meals.  Milk,  buttermilk,  weak  tea,  coffee,  strained 
cocoa,  can  be  taken,  however,  preferably  an  hour  after  meals. 
Meat  should  be  used  sparingly,  not  oftener  than  once  a  day, 
preferably  underdone.  Pork  is  forbidden.  Fish  and  shell  fish 
may  be  taken  if  they  do  not  produce  ill  effects  but  if  they  harm 
once,  they  will  harm  again.  Vegetables  containing  much  fiber 
like  cabbage,  turnips,  carrots,  sweet  potatoes,  etc.,  leave  a  large 
amount  of  waste  and  induce  peristalsis.  The  cereals  and  the 
breakfast  foods  are  all  good.  "Wine  is  the  milk  of  the  aged." 
Light  wines  like  Hock,  Moselle,  Claret,  Burgundy,  etc.,  are  the 
best.  Port,  old  Sherry  and  Madeira  wines  contain  too  much 
alcohol.  Beer  and  ale  may  be  taken  if  they  do  not  produce 
flatulence  or  pyrosis.  The  day  should  be  begun  with  a  glass  of 
hot  water  containing  a  little  table  salt  or  if  constipation  exists 
a  teaspoonful  of  any  of  the  cathartic  salts,  and  at  night  a  glass 
of  hot  milk  may  be  taken  before  going  to  bed.  As  the  aged 
person  is  liable  to  awake  during  the  night  a  glass  of  milk  can  be 
left  at  the  bedside.  Gastric  and  intestinal  disorders  may 
necessitate  modification  of  these  rules.  A  safe  general  rule  is 
to  avoid  all  purin-forming  substances,  foods  containing  much 
cellulose  and  foods  containing  a  large  percentage  of  water. 
This  will  hold  good  for  all  conditions.  Notwithstanding  all 
that  has  been  said  and  written  against  drinking  and  smoking 
most  men  who  have  reached  advanced  age  have  indulged  in 
both.  Everything  in  excess  is  harmful.  As  for  the  determina- 
tion of  what  is  excessive  every  man  is  his  own  judge.  When  a 
man  has  lived  so  rational  a  life  that  he  has  reached  old  age  it 
can  be  safely  left  to  his  own  judgment  to  decide  how  much  he 
can  drink  and  smoke  without  harm. 

The  question  of  exercise  is  intimately  bound  up  with  mentals- 
stimulation.  The  aged  need  mental  and  physical  exercise 
and  recreation,  the  form  of  both  depending  upon  the  mental 
and  physical  condition  of  the  individual  and  the  proper  applica- 
tion of  the  rule  that  recreation  should  be  the  antithesis  of  the 
work  necessitating  it.  Mental  labor,  requires  physical  recrea- 
tion, a  sedentary  occupation  requires  activity,  etc.  The  same 
holds  good  for  the  aged  but  as  all  forms  of  activity  are  diminished 
and  fatigue  sets  in  more  rapidly,  exercise  and  recreation  must 
be  milder  than  in  maturity.  Physical  activity  cannot  be  pro- 
longed on  account  of  the  weakened  locomotory  tissues,  these 
31 


482 


HYGIENE    IN    OLD    AGE 


soon  becoming  tired,  also  on  account  of  the  increased  action  of 
the  heart  and  lungs  which  cannot  keep  up  prolonged  hyperac- 
tivity without  increasing  their  own  degeneration.  Still,  some 
form  of  exercise  is  necessary  to  prevent  stiffening  of  the  joints. 
It  is  hardly  in  place  here  to  discuss  the  theoretical  necessity 
of  exercise  to  produce  heat  and  increase  metabolic  activity. 
Joint  motion  must  be  undertaken  to  prevent  anchylosis,  even 
though  it  increases  waste  which  is  not  repaired.  The  best  form 
of  exercise  for  the  aged  is  walking  up  a  slight  incline  with 
frequent  rests.  This  exercises  the  muscles  of  the  lower  extremi- 
ties and  of  the  back  and  if  a  cane  is  used,  the  muscles  of  the 
upper  extremities  are  also  brought  into  play.  A  walk  through  an 
unfamiliar  forest  path  will  not  alone  give  physical  exercise 
but  will  stimulate  the  brain  and  cause  continual  mental  exhilara- 
tion. Nothing,  however,  equals  a  few  hours  of  fishing  when  fish- 
ing is  good. 

Active  athletics  are  naturally  out  of  the  question,  even 
gymnastics  cannot  be  undertaken,  but  calisthenics  are  beneficial. 
An  imperative  rule  in  all  forms  of  exercise  in  the  aged  is  to 
stop  the  moment  fatigue  sets  in  or  dyspnea  or  palpitation  is 
produced.  Mental  stimulation  cannot  be  continued  beyond 
its  physiological  limit,  for  when  brain  fatigue  sets  in,  the  aged 
individual  falls  asleep.  This  is  seen  in  the  case  of  the  old 
man  who  falls  asleep  during  the  sermon.  It  is  not  lack  of 
attention  but  prolonged  mental  concentration  that  causes  the 
brain  fatigue  and  sleep.  This  should  be  understood  by  speakers 
who  resent  the  seeming  slight  when  an  old  person  falls  asleep 
during  a  sermon  or  lecture.  Even  sensory  stimulation  can 
produce  mental  fatigue,  as  is  seen  when  the  aged  fall  asleep  at 
the  concert  or  spectacular  play.  Mental  stimulation  should 
be  agreeable,  otherwise  it  is  mental  irritation  which  is  depress- 
ing. Discord  in  music,  the  whirl  of  the  dance,  the  shouting 
at  a  game  irritate,  while  melody,  the  harmonious  movements 
of  the  ballet,  catchy  songs  sung  by  a  chorus,  stimulate  and 
create  cheerfulness.  The  play  which  demands  constant  atten- 
tion to  understand  the  slow  unraveling  of  the  plot  is  wasted 
upon  the  old  man,  and  also  the  play  which  is  complicated  or 
where  the  action  is  so  rapid  that  the  mind  cannot  follow  it. 
The  selection  of  the  play,  concert  or  similar  diversion  depends 
upon  individual  taste,  but  the  mental  capacity  should  not  be 


HOME  CARE  OF  THE  AGED  483 

overlooked.  The  outing  is  an  agreeable  form  of  diversion, 
especially  if  young  people  take  part  and  do  not  neglect  the  aged. 
If  the  old  man  likes  fishing  and  hunting  he  may  indulge  in  these 
pastimes,  but  rowing  is  too  strenuous. 

Travel  or  a  change  of  scene  has  often  a  wonderful  effect 
upon  the  mind  of  the  aged.  If  accustomed  to  the  lowlands  or 
seashore  it  is  dangerous  to  take  him  to  high  altitudes.  With 
this  precaution,  the  destination  should  be  a  place  in  which  he 
is  interested  and  which  he  has  not  seen  before,  or  not  in  years. 
The  object  should  always  be,  to  arouse  in  him  an  interest  in 
something  else  than  his  body.  A  favorite  pastime  of  old  people 
consists  in  reading  old  familiar  books,  and  in  gossip.  The 
old  man's  gossip  is  mostly  reminiscences,  the  old  woman's 
does  not  differ  from  the  gossip  of  her  younger  days. 

The  woman  shows  herein  the  greater  interest  in  life,  for 
she  is  interested  in  the  doings  of  her  sisters  while  the  old  man's 
talk  begins  with  "I"  and  ends  with  "me."  But  even  that  is 
better  than  the  reading  of  old  books,  because  he  has  listeners 
who  in  turn  tell  their  tales  of  "I"  and  "me"  and  so  create  new 
interests. 

There  are  many  little  factors  in  and  about  the  house  which 
can  be  included  in  the  hygiene  of  old  age.  The  old  man  should 
have  an  easy  chair  with  padded  arm  rests.  Without  such  rests 
his  hands  lie  in  his  lap  and  his  shoulders  fall  closer  together. 

With  his  arms  on  the  rests  his  shoulders  are  thrown  back,  the 
upper  part  of  his  chest  is  expanded  giving  more  room  for  the 
expansion  of  the  lungs  and  he  breathes  deeper  and  more  freely. 
If  the  chair  is  slightly  tilted  when  he  takes  his  nap  his  head 
will  fall  backward  and  he  will  snore.  If  his  head  falls  forward 
the  vessels  of  the  neck  are  compressed,  which  produces  a  passive 
cerebral  hyperemia,  as  is  evidenced  by  the  flushed  face  and 
injected  conjunctivae  when  he  awakes.  Let  the  old  man 
snore,  but  if  he  groans  while  sleeping  with  his  head  upon  his 
chest,  he  should  be  awakened.  Deafness  and  presbyopia  are 
common  ailments  and  the  former,  especially,  causes  mental 
depression  and  may  lead  to  oikiomania  and  melancholia. 
The  old  are  selfish  and  suspicious,  they  feel  they  are  practically 
useless,  that  they  are  a  burden  upon  those  who  look  after  them. 
When  they  cannot  hear  what  is  said  around  them,  a  glance  in 
their  direction  is  sufficient  to  arouse  in  them  the  suspicion  that 


484 


HYGIENE    IN    OLD    AGE 


they  are  the  subject  of  a  conversation  held  in  their  presence, 
and  such  suspicions  invariably  lead  to  perverted  conclusions. 
To  avoid  this,  as  soon  as  it  is  noticed  that  an  aged  person  makes 
an  effort  to  hear  what  is  said,  that  he  turns  one  ear  to  the  speaker 
or  watches  the  movements  of  the  lips,  or  gives  other  evidence 
that  hearing  is  becoming  impaired,  he  should  be  furnished  with 
a  speaking  tube  or  other  appliance  to  improve  his  hearing. 

Drugs  are  useless.  If  the  sight  is  impaired  the  nature  of 
the  impairment  should  be  ascertained.  In  most  cases  it  is 
simply  a  presbyopia  which  can  be  remedied  by  proper  glasses. 
It  may  be  cataract  or  a  progressive  amaurosis  probably  due 
to  senile  degeneration  of  the  optic  nerve. 

The  aged  are  grateful  for  little  attentions,  such  as  an  occa- 
sional nosegay,  but  if  given  for  several  days  in  succession  they 
expect  them  and  a  single  neglect  to  furnish  them  is  cause  for 
complaint.  The  memory  of  such  neglect  is  hoarded  and 
brooded  over  for  days.  If  the  old  man  or  woman  has  a  harmless 
hobby  which  is  not  silly  and  will  not  expose  the  individual  to 
ridicule  or  interference,  it  should  be  encouraged.  Unfortunately 
the  hobbies  of  the  aged  are  not  always  harmless,  they  are  often 
childish,  sometimes  insane.  It  is  extremely  difficult  to  break 
an  old  person  of  a  new  hobby,  especially  if  it  involves  sexual 
perversion  or  other  moral  defect.  As  the  moral  sense  becomes 
blunted  he  cannot  be  made  to  realize  the  wrong  in  his  actions 
and  it  may  become  necessary  to  instil  fear  of  punishment  to 
hold  him  in  check.  As  the  mental  and  physical  powers  wane, 
the  aged  find  comfort  in  the  association  with  children,  especially 
in  the  companionship  of  a  favorite  grandchild  or  niece.  Much 
can  be  done  with  them  through  the  influence  of  such  favorite 
child,  and  such  companionship  should  be  fostered.  The  wide- 
spread belief  that  the  aged  regain  youthful  vigor  at  the  expense 
of  the  child  has  nothing  to  uphold  it. 

The  family  should  be  taught  to  observe  slight  changes 
in  the  physical  condition  and  demeanor  of  the  aged  under  their 
care.  The  symptoms  of  disease  begin  so  insidiously  and  pro- 
gress so  mildly  that  a  grave  disease  may  be  far  advanced  before 
the  family  realizes  that  the  patient  is  ill.  The  aged  seldom 
complain  of  pain  or  give  other  marked  symptoms  of  disease, 
the  mind  and  the  perception  of  pain  being  blunted  and  it 
frequently    happens    that    the    earliest    manifestation    of    the 


HOME  CARE  OF  THE  AGED  485 

disease  is  collapse.  When  an  aged  individual  who  is  accus- 
tomed to  be  up  and  around  shows  a  disinclination  to  leave  his 
bed,  it  indicates  a  rapidly  growing  weakness  such  as  accompanies 
senile  pneumonia.  The  family  says  he  is  failing  rapidly  while 
it  may  be  the  exhaustion  which  accompanies  a  grave,  probably 
a  fatal,  disease.  When  the  aged  individual  talks  in  his  sleep, 
and  has  never  before  done  this,  we  have  probably  a  low  mutter- 
ing delirium  indicating  a  cerebral  disorder.  The  family  should 
learn  that  a  cool  forehead  may  exist  with  high  fever,  that  surface 
temperature  is  no  indication  of  body  temperature.  A  chill  is 
always  a  signal  of  danger  requiring  immediate  attention.  Vom- 
iting after  a  heavy  meal  is  often  the  first  sign  of  acute  gastritis 
which  is  always  a  grave  disease  in  the  aged.  If  he  is  too 
long  in  the  toilet  he  may  have  fallen  asleep  or  he  may  be 
straining  to  relieve  a  distended  bladder  which  is  blocked  by  a 
calculus  or  a  hypertrophied  prostate.  A  cold  sweat  on  a  pale 
face  is  a  grave  symptom  generally  indicating  collapse.  There  are 
many  causes  for  coma  but  when  occurring  in  old  age  only  that 
of  apoplexy  and  embolism  is  sudden  and  without  antecedent  rec- 
ognized chronic  disease.  If  the  face  is  flushed,  the  head  should 
be  raised  and  ice  bags  applied.  If  the  face  is  pale,  hot  applica- 
tions should  be  placed  upon  the  head  while  the  patient  lies  on 
his  back  with  the  head  low.  The  same  rule  holds  good  if  there 
is  headache.  Anorexia  is  not  a  dangerous  symptom  by  itself 
and  is  frequently  due  to  gastric  catarrh.  If  there  are  other 
symptoms  not  pointing  to  gastric  disorder,  there  is  probably 
some  serious  disease  present,  anorexia  being  one  of  the  earliest 
symptoms  of  inflammatory  conditions.  Sudden  irritability  in- 
dicates either  mental  disorder  or  distress,  perhaps  not  amount- 
ing to  pain.  If  the  patient  complains  of  pain  anywhere  it 
should  receive  immediate  attention.  Occasionally  the  aged  will 
complain  of  pain  to  arouse  sympathy.  It  is  difficult  to  detect 
such  malingerers,  especially  if  they  refer  the  pain  to  some 
internal  organ.  Repeated  examinations  may  be  necessary, 
but  the  individual  generally  betrays  himself  by  forgetting  the 
spot  where  he  located  the  pain  at  the  former  examination. 

INSTITUTIONAL  CARE  OF  THE  AGED 

What  has  been  said  in  the  preceding  chapter  applies  to  a 
great  extent  to  the  care  of  the  aged  in  asylums.     There  is, 


486 


HYGIENE   IN   OLD   AGE 


however,  a  vast  difference  between  the  asylum  and  the  home, 
and  between  asylums  among  themselves,  and  the  care  bestowed 
upon  their  inmates.  There  are  private  asylums,  sectarian  and 
unsectarian,  to  which  a  large  admission  fee  is  paid,  private 
asylums  maintained  by  organizations  for  their  members  who 
have  contributed  toward  them  and  hence  have  a  proprietary 
right  to  them,  semi-private  asylums  maintained  by  nation- 
alities, churches  and  vocations  for  those  of  the  same  nation- 
ality, church  or  vocation,  and  public  asylums  or  poor-houses. 
The  care  bestowed  upon  the  inmates  naturally  depends  upon 
the  class  of  institution.  Those  who  pay  large  admission  fees 
belong  to  a  strata  of  society  in  which  refinement  in  surround- 
ings is  imperative,  luxuries  are  necessities  and  the  utmost  care 
is  expected.  At  the  other  extremity  is  the  poor-house,  the 
inmates  of  which  are  paupers  from  the  slums  of  the  city  and  the 
poorest  inhabitants  of  the  country.  One  fundamental  differ- 
ence between  the  aged  at  home  and  in  the  asylum  is  in  the 
mental  attitude.  In  the  asylum  there  is  freedom  from  care 
about  the  future,  from  worry  about  the  family  to  whom  the 
individual  had  probably  been  a  burden,  and  from  fear  that  the 
family  is  trying  to  get  rid  of  him  and  might  go  to  extreme 
measures  to  secure  relief  from  the  incubus.  There  is  on  the 
other  hand  the  feeling  of  dependence  and  a  sense  of  lost  inde- 
pendence, restrictions  in  many  directions,  in  actions,  in  food, 
perhaps  in  clothes,  the  inmate  must  obey  rules,  perform  tasks, 
and  above  all  he  must  not  complain.  In  the  public  asylums 
there  is  a  sense  of  absolute  helplessness,  the  inmate  feels  that 
he  is  dependent  upon  the  bounty  of  every  individual  in  the 
community,  that  complaint  will  be  followed  by  punishment, 
that  he  is  virtually  a  beggar  without  rights.  Under  such  cir- 
cumstances the  inmates  of  alms-houses  become  morose,  apa- 
thetic, they  lose  interest  in  everything  except  themselves,  and 
melancholia  and  senile  dementia  follow.  It  is  impossible  to 
arouse  in  them  any  sense  of  pride  in  appearance,  any  ambition, 
or  interest  in  anything. 

In  New  York  City  the  name  alms-house  has  been  changed  to 
City  Home  for  the  Aged  and  Infirm.  This  has  had  an  elevat- 
ing influence  upon  the  inmates  who  are  now  no  longer  paupers 
of  the  alms-house,  but  inmates  of  the  city  home.  The  estab- 
lishment of  the  city  farms  for  them  has  had  a  further  beneficial 


INSTITUTIONAL  CARE  OF  THE  AGED  487 

effect  in  stimulating  interest — the  great  desideratum  in  dealing 
with  the  aged.  In  a  great  public  institution  intended  for  all 
races,  religions  and  nationalities,  the  inmates  form  sets  and 
cliques  based  upon  similarity  in  race,  religion  or  nationality 
and  this  gives  rise  to  jealousies  and  ill-will.  The  inmates  being 
drawn  mainly  from  the  lowest  strata  of  society,  they  comprise 
the  quizzical  and  querulous,  the  shrinking  and  the  defying,  the 
meek  and  the  humble,  and  the  dominating  spirits  found  in  the 
slum  sections  of  the  cities,  and  harshness  is  often  necessary  to 
enforce  order  among  them.  With  such  characters  kindness  is 
construed  into  weakness  and  it  requires  tact,  patience  and 
firmness  to  prevent  excesses,  especially  if  crippled  and  aged 
are  thrown  promiscuously  together.  The  leaders  in  com- 
plaints and  demands  are  generally  the  cripples  who,  being  men- 
tally brighter  than  the  aged  succeed  in  securing  better  treatment, 
often  better  food  than  the  others.  In  institutions  where  the 
aged  have  light  tasks  assigned  to  them  they  do  not  break  down 
mentally  either  as  soon  or  as  completely  as  where  the  aged  have 
nothing  to  do  but  sit  on  a  bench  and  brood.  In  the  large  state 
institution  at  Lainz  near  Vienna,  which  the  author  visited,  the 
inmates  receive  counters  representing  money  which  can  be 
exchanged  at  a  canteen  on  the  grounds  for  beer,  tobacco  and 
other  little  luxuries.  In  this  way  they  receive  a  few  cents  each 
day  and  a  certain  amount  of  beer  or  tobacco.  To  prevent  the 
ennui  which  leads  to  melancholia,  the  inmates  follow  their 
vocations  in  the  institution,  as  far  as  they  are  able,  and  go 
twice  daily  to  the  canteen  which  is  fitted  up  as  a  "bier  stube." 
They  have  a  band,  and  in  other  ways  their  interest  in  life  is 
maintained.  They  are  naturally  under  restrictions,  but  they 
are  at  liberty  to  go  and  come  at  will  within  certain  hours,  and 
the  depressing  idea  that  they  are  paupers  is  not  forced  upon 
them. 

The  care  of  the  aged  in  public  institutions  depends  as  much 
upon  the  intelligence,  tact  and  humanity  of  the  person  in  charge 
as  upon  the  funds  at  his  disposal.  It  is  naturally  impossible  to 
give  individual  attention  to  each  inmate  where  there  are  many, 
but  it  is  possible  to  stimulate  individual  interest  in  each  one's 
welfare.  It  is  likewise  possible  to  make  the  inmates  more 
cheerful,  rouse  them  out  of  the  lethargy  into  which  newcomers 
soon  sink,  and  prolong  their  lives.     The  aged  like  attention, 


488  HYGIENE   IN    OLD   AGE 

but  they  do  not  like  the  attention  of  the  sightseer  who  views 
them  as  curiosities.  Neither  do  they  want  the  patronizing  and 
pitying  expressions  of  sympathy  from  the  philanthropists  who 
give  nothing  else  but  sympathy.  These  two  classes  should  be 
excluded  from  the  public  institutions.  Inmates  who  do  no  work 
need  no  recreation  and  they  do  not  want  any.  Work,  however, 
stimulates  the  mind  and  body  and  recreation  is  then  appre- 
ciated. The  women  should  look  after  their  rooms  and  be  per- 
mitted to  do  such  work  as  they  are  able  to  do  in  the  kitchen, 
and  they  should  be  given  the  opportunity  to  do  needle  work 
which  can  be  sold  and  part  of  the  proceeds  be  turned  over  to 
them.  Even  the  pauper  in  the  alms-house  feels  that  he  is  not 
absolutely  worthless  if  he  can  do  something  and  receive  pay  for 
his  work.  It  need  not  be  much,  a  few  cents  a  day  which  the 
individual  can  call  his  or  her  own,  will  suffice.  The  sense  of 
proprietorship  if  only  of  a  few  cents  arouses  the  self-respect 
that  is  crushed  under  the  depressing  feeling  that  one  is  a  pauper. 
This  was  demonstrated  to  the  author  in  his  visit  to  the  Austrian 
institution. 

The  medical  care  of  the  aged  in  the  public  institutions 
should  receive  the  same  attention  as  in  the  public  hospitals. 
In  an  asylum  in  New  York  city  the  windows  of  the  dormitory 
were  left  open  all  day,  while  the  bedding  was  turned  back  over 
the  foot  of  the  bed  to  permit  both  the  bed  and  bedding  to  be 
thoroughly  aired.  At  night  the  windows  were  closed,  the  heat 
turned  on,  and  the  bedding  properly  arranged  for  the  night. 
The  beds  were  cold  when  the  inmates  retired  and  the  old  people 
were  chilled.  Those  that  had  bronchitis  at  once  gave  evidence 
of  it  and  their  coughing  kept  those  awake  who  had  no  such 
disease.  It  is  impossible  to  sleep  in  a  cold  bed  until  the  heat  of 
the  body  has  warmed  the  bed  sufficiently  to  keep  the  sleeper 
comfortable.  The  aged  have  a  lower  surface  temperature, 
radiation  is  less  active  and  it  takes  much  longer  to  warm  the 
bed  by  the  body  of  an  old  person  than  it  does  by  that  of  a 
younger  and  more  active  individual.  This  contributed  to  keep 
the  old  people  in  the  institution  awake  for  several  hours  after 
they  went  to  bed,  and  could  have  been  avoided  by  warming  the 
bed  before  they  occupied  it. 

Social  intercourse  between  the  sexes  should  be  permitted. 
To  keep  them  apart,  as  is  usually  done,  deprives  them  of  one 


INSTITUTIONAL  CARE  OF  THE  AGED  489 

of  the  main  sources  of  pleasure  that  they  had  before  entering 
the  institution.  No  good  reason  has  ever  been  given  why  they 
should  be  kept  apart.  Even  in  semi-private  and  private  homes 
this  segregation  is  maintained,  yet  in  some  places  where  this 
barrier  is  removed  the  inmates  form  a  large  family  party  and 
greater  interest  is  shown  in  the  home  and  in  each  other. 

Too  much  stress  cannot  be  laid  upon  the  necessity  for  mental 
and  physical  employment  in  all  classes  of  institutions,  and  for 
both  sexes.  There  should  be  some  system  in  the  distribution 
of  labor,  and  the  work  must  be  of  such  a  nature  that  sudden 
and  prolonged  intermission  will  not  destroy  it,  and  another 
person  can  take  it  up  where  one  drops  it.  The  aged  delight 
in  completed  tasks  and  they  are  stimulated  to  further  efforts. 
The  work  therefore  should  be  light  and  of  such  a  character  that 
it  can  be  completed  in  a  few  days  or  weeks;  it  should  offer  a 
variation  so  as  not  to  become  monotonous,  and  there  should 
be  no  element  of  danger  connected  with  it.  Farm  work  is  hard 
yet  there  are  many  light  tasks  about  the  farm  which  meet  all 
the  requirements  of  physical  labor  for  the  aged.  Gardening, 
especially  the  care  of  potted  plants,  is  an  agreeable  occupation 
for  the  aged,  and  a  little  commendation  for  their  work  incites 
them  to  continued  efforts.  It  is,  however,  not  advisable  to 
create  rivalry  among  the  inmates  of  a  home  in  tasks  the  out- 
come of  which  is  beyond  their  control,  as  in  the  growing  of  plants. 

The  recreations  of  the  inmates  of  homes  depend  upon  their 
mental  and  physical  capacity  and  the  character  of  the  work 
which  requires  recreation.  The  depressing  influence  of  the 
public  alms-house  causes  rapid  mental  and  physical  deteriora- 
tion and  the  inmates  seek  few  recreations.  They  should  be 
supplied  with  work  and  diversions.  Those  who  can  play  a 
musical  instrument  should  be  given  the  opportunity  to  do  so. 
There  is  no  better  collective  recreation  than  an  orchestra  com- 
posed of  inmates  and  concerts  given  by  them.  Dancing  and 
athletics  are  dangerous,  but  social  parties,  masquerades,  out- 
ings, etc.,  are  harmless  and  agreeable.  Such  diversions  involve 
little  expense,  yet  this  little  is  given  grudgingly  or  not  at  all  by 
communities  that  see  in  the  aged  paupers  only  economically 
worthless  burdens. 

The  favorite  pastime  of  the  aged  is  gossip.  This  does  no 
harm.     When  they  take  up  reading  it  is  either  something  of 


4q0  HYGIENE    IN    OLD    AGE 

a  religious  character  or  some  favorite  work  that  they  had  read 
and  re-read  over  and  over.  They  picture  anew  the  scenes 
described  and  live  again  in  the  world  of  yesterday.  Even 
this  is  better  than  no  reading  at  all,  although  it  does  not  arouse 
the  same  mental  activity  as  a  new  book.  There  will  always 
be  found  some  inmates  of  homes  who  keep  up  their  interest 
in  the  world  of  to-day,  in  the  passing  events,  new  books,  art, 
and  science.  Such  inmates  should  receive  every  opportunity 
to  improve  their  minds.  The  newspapers  and  popular  magazines 
are  better  than  novels,  as  they  do  not  require  prolonged  and 
concentrated  interest.  Card  playing  is  a  simple  pastime,  the 
simpler  games  which  require  no  mental  effort  being  extremely 
popular  in  institutions  where  this  pastime  is  permitted.  Lotto, 
checkers  and  the  various  home  games  in  which  the  chance 
fall  of  the  dice  determines  the  issue,  all  keep  the  mind  engaged 
without  involving  strain  or  prolonged  attention. 

In  public  institutions  individual  likes  and  dislikes  are 
disregarded.  It  is  naturally  impossible  to  conform  to  the 
desires  of  each  inmate,  but  in  many  instances  concessions  can 
be  made,  especially  in  relation  to  food,  that  may  lengthen  the 
life  of  the  individual  and  make  him  happier.  A  Jewish  inmate 
of  a  public  (non-sectarian)  institution  would  not  eat  certain 
articles  of  food  proscribed  by  his  faith  and  as  he  could  get  no 
other  food,  he  became  weakened  from  insufficient  nutrition. 
He  was  removed  to  an  institution  of  his  own  faith  and  rapidly 
gained  in  weight  and  strength.  The  remarkable  showing  of 
the  Jewish  homes  for  the  aged  is  probably  due  to  the  greater 
care  bestowed  upon  the  food,  especially  upon  the  meats. 
(Longevity  among  Jews  in  spite  of  unsanitary  surroundings  is 
believed  to  be  due  to  their  sobriety  and  sanitary  regulations 
regarding  food.)  It  is  impossible  to  arrange  a  diet  list  which 
would  be  generally  applicable  to  all  classes  of  institutions  or 
even  to  all  the  inmates  of  one  class.  The  general  dietetic  rules 
given  in  the  last  chapter  will  apply  here,  but  there  are  naturally 
many  exceptions.  A  different  diet  is  necessary  for  those  who 
have  no  teeth  from  the  diet  of  those  who  can  chew  their  food. 
As  constipation  is  a  common  complaint  among  the  aged,  foods 
having  this  tendency  should  be  avoided  These  include  fresh 
bread,  eggs,  liver,  pork,  rice  pudding,  sago  pudding,  milk,  nuts, 
cheese  and  preserved  (salt,  potted  or  smoked)  meats  and  fish. 


INSTITUTIONAL  CARE  OF  THE  AGED  49 1 

A  pernicious  practice  which  the  author  found  in  vogue  in  one 
institution  was  the  addition  of  a  cathartic  to  some  article  of 
food  once  a  week.  Drugs  should  not  be  given  indiscriminately, 
but  each  case  should  receive  individual  care.  Bladder  and 
intestinal  troubles  are  common  among  the  inmates  of  institu- 
tions and  they  are  generally  due  to  neglect,  occasionally  to 
inadequate  toilet  arrangements.  An  apparently  insignificant 
omission  in  one  institution  caused  the  inmates  much  annoyance. 
They  were  not  permitted  to  go  barefoot,  there  was  no  carpet 
on  the  floor  of  the  hall  and  the  toilet  was  at  one  corner.  Several 
of  the  inmates  were  suffering  from  dilatation  of  the  bladder  and 
walking  in  their  shoes  on  the  bare  floor  at  night  disturbed  the 
whole  dormitory.  A  strip  of  carpet  removed  this  source  of 
insomnia.  Where  a  large  number  of  aged  individuals  are 
collected,  daily  baths,  either  tub  or  shower,  become  necessary. 
Constant  vigilance  is  required  to  prevent  an  invasion  of  para- 
sites, for  once  they  gain  a  foothold  it  may  become  necessary 
to  quarantine  the  whole  institution,  giving  the  inmates  their 
freedom,  one  by  one,  after  each  had  been  subjected  to  a  steriliz- 
ing process  or  bath.  The  bath  is  also  necessary  on  account  of 
the  bromidrosis  common  among  the  aged  and  which  they  do 
not  perceive  owing  to  the  impairment  of  their  olfactory  organs. 

A  distinctive  costume  is  as  humiliating  to  the  pauper  as  it 
is  to  the  prisoner  and  it  crushes  self-respect  more  certainly 
than  the  prison  stripes.  Throughout  this  work  stress  has  been 
laid  upon  psychic  influence  upon  the  organism  and  the  sense  of 
well-being  of  the  aged.  If  we  wish  to  improve  the  sense  of 
well-being  that  conduces  to  happiness,  we  must  avoid  depress- 
ing influences  and  especially  such  that  mortify  and  humiliate 
the  aged.  Such  humiliation  and  the  sense  of  inability  to  repair 
the  cause,  or  attack  the  offender,  destroy  what  little  dignity 
and  self-esteem  the  individual  has  left  after  accepting  the 
bitter  bread  of  charity.  This  soon  leads  to  melancholia  and 
dementia.  The  only  advantage  in  having  uniform  costumes 
of  a  distinctive  pattern  is  to  make  supervision  simpler;  possibly, 
too,  there  is  a  slight  saving  in  the  expense  of  clothing  the  inmates. 
Neither  advantage  is  comparable  to  the  advantage  derived 
by  the  inmates  from  the  knowledge  that  they  are  not  obliged 
to  wear  the  costume  of  the  pauper. 

In  homes  holding  a  large  number  of  inmates,  those  having 


4g2  HYGIENE    IN    OLD    AGE 

marked  mental  deterioration  should  be  removed  from  the  others. 
As  age  advances  many  individuals  become  imitative  like 
children  and  they  are  likely  to  imitate  the  actions  and  talk  of 
the  dullest  of  the  inmates.  Others  become  depressed  when 
they  are  compelled  to  associate  with  dements,  and  may  become 
likewise  affected. 

Many  find  in  religion  the  consolation  that  makes  them 
resigned  to  the  inevitable.  Aged  women  are  especially  amenable 
to  religious  influences  and  ministers  of  the  Gospel  find  no  more 
grateful  subjects  than  the  inmates  of  homes  for  aged  women. 
Every  opportunity  should  be  given  the  inmates  to  worship 
according  to  their  own  faith  and  while  it  may  not  be  practicable 
to  have  a  separate  chapel  for  each  sect,  where  there  is  but  one 
chapel  it  can  be  so  fitted  up  that  it  will  meet  the  requirements 
of  the  two  great  branches  of  Christianity,  worshipping  at 
different  hours.  Hebrews  will  not  worship  in  a  Christian  chapel, 
but  if  there  are  many  of  that  faith  in  a  public  non-sectarian 
institution  any  room  can  be  converted  into  a  temporary  syna- 
gogue in  a  few  minutes  and  at  little  expense.  The  head  of  such 
an  institution,  accustomed  to  handle  all  faiths  and  sects,  will 
know  the  fast  days  and  feast  days  of  the  Catholics,  the 
Passover,  the  day  of  Atonement  and  other  fast  days  of  the 
Hebrews  and  other  holidays  kept  by  other  faiths.  The  most 
important  regulations  to  be  observed  on  such  days  relate  to 
food.  If  the  head  of  such  institution  is  ignorant  of  them,  he 
can  call  to  his  aid  either  a  well-informed  inmate  or  a  priest, 
minister  or  rabbi  who  will  gladly  advise  him. 

In  all  homes  for  the  aged,  except  the  alms-houses,  there  is 
a  community  of  interest ;  it  may  be  of  religion  or  nationality  or 
vocation,  which  binds  all  to  a  common  object.  There  is  also  a 
sense  of  proprietary  interest  in  the  vocational,  organization  and 
private  homes,  which  raises  the  inmates  out  of  the  class  of 
paupers  and  dependents  and  entitles  them  to  privileges  and  care 
which  those  in  the  alms-house  have  no  right  to  demand.  In 
the  free  homes  maintained  for  certain  nationalities  and  sects, 
the  inmates  are  dependents  but  little  better  than  paupers,  and 
while  the  surroundings  are  far  superior  to  the  surroundings  in 
the  alms-house  and  the  care  is  better,  the  inmates  are  still  under 
the  depressing  influence  of  the  sense  of  dependence  upon  the 
bounty  of  others.       If  we  wish  to  increase  the  feeling  of  well- 


INSTITUTIONAL  CARE  OF  THE  AGED  493 

being  in  the  aged  we  must  remove  depressing  influences.  To 
the  sensitive  person  the  idea  of  being  dependent  upon  charity 
is  most  humiliating,  and  if  this  idea  is  being  constantly  kept 
before  the  individual  it  will  produce  melancholia  and  it  has  led 
to  suicide.  For  this  reason  let  me  repeat,  the  sight-seer  and  the 
professional  sympathizer  should  be  kept  out  of  such  institutions 
and  the  inmates  should  be  allowed  slight  liberties,  such  as  to 
go  and  come  at  will  within  certain  hours,  receive  visitors,  do 
work  which  will  not  interfere  with  the  orderly  conduct  of  the 
asylum,  receive  pay  for  such  work  and  spend  their  earnings. 
At  the  same  time  rules  relating  to  the  introduction  of  unsuitable 
food  and  drink  should  be  rigidly  enforced  even  to  the  extent  of 
expulsion  of  an  inmate  who  brings  in  such  articles  surreptitiously. 

Institutions  of  this  kind  often  receive  gifts  of  clothing.  If 
worn  clothing  is  received,  it  should  be  disinfected  before  distri- 
bution and  the  distribution  should  be  made  individually  and  in 
private,  not  as  a  public  exhibition. 

The  vocational  homes  are  generally  homes  of  vocational 
organizations  toward  the  maintenance  of  which  the  inmates 
have  contributed,  or  else  homes  under  government  supervision 
for  those  who  have  been  engaged  in  hazardous  government 
occupations,  and  are  offered  as  an  inducement  and  prospective 
reward  to  those  engaging  in  such  work.  A  few  vocational  homes 
were  founded  by  individual  bequest  and  these  are  so  well 
endowed  that  nothing  is  lacking  to  make  the  inmates  contented 
and  supply  them  with  everything  that  can  contribute  to  their 
welfare.  The  government  asylums  are  mainly  for  soldiers  and 
sailors,  men  accustomed  to  government  routine  and  control 
and  unaccustomed  to  home  influences.  These  men  can  readily 
accommodate  themselves  to  the  new  conditions  and  are  not  sub- 
jected to  the  mental  depression  associated  with  the  idea  of 
dependence  upon  charity.  There  is  no  such  revolutionary 
change  in  their  mode  of  life  upon  entering  a  government  home  as 
occurs  in  the  life  of  the  private  individual  who  leaves  his  own 
home  and  family  to  enter  an  asylum.  The  vocational  homes 
maintained  by  vocational  organizations  are  like  the  homes 
maintained  by  fraternal  organizations,  private  institutions 
to  which  the  inmates  have  a  certain  proprietary  right.  Most 
organization  asylums  admit  both  sexes  and  thereby  make 
institutional  life  more  agreeable.     To  the  old  man  or  woman 


494  HYGIENE   IN   OLD   AGE 

accustomed  to  associate  with  the  opposite  sex,  the  sudden  and 
complete  deprivation  of  such  association  must  produce  a 
profound  change  in  the  mental  attitude.  If,  in  addition  thereto, 
there  is  a  change  in  the  home  surroundings  and  in  the  mode  of 
living,  the  temperament  of  the  individual  becomes  altered. 
This  is  a  common  observation  in  homes  for  the  aged.  The 
inmate  soon  after  admission  improves  mentally  and  physically 
through  the  freedom  from  care,  changed  surroundings  and  a 
more  regular  mode  of  life.  After  a  few  weeks  a  temperamental 
change  is  noted  and  this  depends  upon  the  difference  between 
the  new  mode  of  life  and  the  life  to  which  he  had  been  ac- 
customed. In  a  small  house  where  the  sexes  mingle,  as  in  the 
Actors'  Fund  Home  on  Staten  Island,  New  York,  the  inmates 
form  a  large  family.  They  occupy  a  cottage-like  building  which 
is  to  them  a  real  home,  not  an  asylum  or  an  institution.  They 
find  here  an  approach  to  home  conditions  under  probably  more 
wholesome  surroundings  than  formerly,  with  freedom  from  care 
about  the  future.  This  is  an  ideal  home  for  the  aged.  The 
cottage  plan  of  housing  the  old  has  received  but  little  attention 
in  this  country,  although  the  results  obtained  in  the  few  small 
institutions  occupying  homelike  cottages  ought  to  commend  it 
to  those  interested  in  the  welfare  of  the  aged.  Where  the 
cottage  plan  is  impracticable,  an  effort  should  be  made  to  copy 
home  life  as  far  as  possible,  by  having  small  sleeping  rooms 
instead  of  large  dormitories,  permitting  aged  couples  to  remain 
together,  and  fitting  up  their  room  with  pictures  and  decorations 
from  their  old  home,  observing  of  course  sanitary  precautions. 
True,  such  an  arrangement  may  give  sleeping  rooms  a  bizarre 
appearance  and  detract  from  the  sense  of  order  and  neatness; 
it  will,  however,  conduce  to  the  happiness  of  the  individual  and 
may  arouse  worthy  emulation  and  rivalry  among  the  inmates. 
The  object  is,  after  all,  to  increase  the  happiness  and  prolong 
the  lives  of  the  aged  persons  by  making  them  feel  as  much  "at 
home"  as  is  possible  under  institutional  conditions  and  by 
preventing  and  relieving  the  little  ailments  which  embitter  and 
shorten  their  lives. 
^  In  all  homes  for  the  aged,  music  is  the  most  acceptable  and 
probably  the  most  beneficial  diversion.  Even  in  the  alms-house 
inmates  will  often  be  found  who  can  play  a  musical  instrument 
and  who  would  gladly  join  an  orchestra  composed  of  inmates. 


INSTITUTIONAL  CARE  OF  THE  AGED  495 

In  such  a  nondescript  orchestra  it  is  not  expected  that  the  broken- 
winded  trombone  player  will  go  through  a  Wagnerian  opera 
or  the  tremulous  fingers  of  the  aged  violinist  will  do  justice 
to  a  nocturne.  The  aged  prefer  melody  to  harmony,  and  the 
old-time  airs — which  stimulate  memory — to  the  airs  of  to-day. 
Not  infrequently  an  old  familiar  air  will  rouse  an  individual 
from  apathy  and  stimulate  interest  in  life.  To  see  an  old 
pianist  surrounded  by  a  group  of  aged  persons  who  are  trying 
to  sing  in  unison  some  sentimental  song  of  a  generation  ago  is  a 
pathetic  sight  to  the  on-looker,  but  to  the  singers  it  means 
pleasure  and  happiness.  In  many  other  ways  can  the  pleasures 
and  happiness  of  the  aged  in  institutions  be  enhanced.  Men 
should  be  permitted  to  smoke  in  the  open,  but  not  in  closed 
rooms;  to  play  cards  and  other  games,  but  not  such  as  require 
much  mental  concentration  or  involve  sudden  exciting  moments ; 
harmless  hobbies  should  not  be  interfered  with,  and  little  pec- 
cadilloes should  be  condoned.  At  no  time  in  life  does  the 
vanity  of  women  appear  more  silly  than  in  old  age;  yet  the 
vanity  of  the  aged  woman  shown  in  an  effort  to  appear  younger 
and  more  charming  is  an  indication  of  her  interest  in  life. 
Instead  of  being  condemned,  this  vanity  or  pride  in  appearance 
should  be  encouraged.  The  use  of  cosmetics  does  no  harm  nor 
does  any  harm  result  from  her  efforts  to  dress  in  the  prevailing 
fashion.  Flattery  is  as  agreeable  to  the  woman  of  seventy  as 
to  the  girl  of  seventeen  and  is  more  beneficial.  Care  in  dress 
and  order  in  the  room  should  be  rigidly  enforced,  while  increas- 
ing disorder  in  dress,  appearance  or  surroundings  should  be 
looked  upon  as  a  gradual  weakening  of  the  emotions  and  of  the 
mind  as  a  whole. 

The  general  lack  of  interest  in  geriatrics  is  responsible  for 
the  general  neglect  of  the  minor  ailments  of  the  aged.  Some  of 
these  ailments  have  a  pernicious  psychic  reaction,  leading  to 
delusions,  which,  with  the  increasing  mental  weakness,  form  senile 
paranoia.  Presbyopia  is  generally  neglected,  little  attention  is 
paid  to  the  teeth,  virtually  no  attention  is  given  to  broken-down 
arches,  or  corns,  bunions,  and  other  pedal  defects.  The  old 
man  complains  of  pains  and  aches  and  they  are  set  down  as 
"rheumatic;"  it  is  taken  for  granted  that  the  old  man  will  be 
constipated,  and  must  urinate  frequently ;  that  the  aged  woman 
will  have  varicose  veins  and  perhaps  chronic  ulcers  on  the  legs, 


496 


HYGIENE    IN    OLD    AGE 


intertrigo  under  the  breasts,  etc.  Senile  emphysema,  senile 
tremor,  senile  debility,  are  dismissed  with  the  remark  "old  age," 
and  nothing  more  is  done  for  the  sufferer. 

Senility  is  a  state  of  physiological  valetudinarianism.  It 
requires  special  study,  not  as  a  pathological  condition  of  ma- 
turity, but  as  an  entity  entirely  apart  from  maturity  and  the 
person  having  charge  of  an  institution  for  the  aged  should  have 
the  knowledge  that  comes  from  such  study.  This  applies  just 
as  well  to  the  physician  who  treats  the  ailments  of  the  aged. 


MEDICO-LEGAL  RELATIONS 


The  most  important  and  most  frequent  legal  questions 
arising  in  connection  with  senility  relate  to  the  mental  condi- 
tion of  the  individual  when  making  a  will.  It  is  recognized 
that  old  age  carries  with  it  mental  impairment.  Mental  im- 
pairment is  part  of  the  organic  and  functional  changes  that 
constitute  ageing,  it  is  progressive,  there  are  no  remissions  and 
it  terminates  in  complete  obliteration  of  the  intellect.  Long 
before  this,  the  reasoning  faculty  and  judgment  become  so 
impaired  that  the  individual  does  not  comprehend  the  nature 
of  his  acts,  while  memory  is  so  weakened  that  he  does  not  know 
the  extent  of  his  property  or  those  who  have  natural  claims 
upon  him. 

The  mental  functions  and  faculties  do  not  become  weakened 
uniformly  and  we  consequently  find  some  faculties  stronger 
than  others.  Thus  reason  may  be  apparently  as  strong  as  in 
maturity  yet  memory  and  volition  profoundly  weakened.  If 
there  is  a  delusion,  illusion  or  hallucination  present,  we  have  a 
form  of  insanity  to  deal  with,  a  different  proposition  from  the 
question  of  senile  mental  impairment. 

It  has  been  held  that  testamentary  capacity  is  destroyed 
by  actual  weakness  of  the  mind,  ' '  by  anything  that  will  weaken 
the  individual's  memory,  judgment  and  volition  in  relation  to 
the  disposal  of  his  property  or  the  objects  of  his  bounty."  This 
might  be  made  to  include  slight  impairment,  not  sufficiently 
marked  to  attract  the  attention  of  the  stranger  who  is  not 
familiar  with  the  normal  mental  condition  of  the  individual. 
In  another  decision  the  judge  declared,  "the  rule  is  that  to 
avoid  an  instrument  on  the  ground  of  the  alleged  mental  inca- 
pacity of  the  person  who  executed  the  same,  such  person  must 
have  been  so  deprived  of  his  mental  faculties  as  to  be  wholly 
unable  to  understand  or  comprehend  the  nature  of  the  trans- 
action." Other  decisions  place  other  constructions  upon  the 
condition  of  mind  necessary  to  indicate  testamentary  capacity. 
When  memory  has  become  so  defective  that  the  aged  individual 
32  497 


.gg  MEDICO-LEGAL    RELATIONS 

does  not  know  the  extent  of  his  property  or  the  persons  who  have 
a  natural  claim  upon  it,  or  judgment  is  so  weakened  that  he 
cannot  intelligently  dispose  of  it,  his  mental  condition  has 
passed  beyond  simple  impairment;  it  is  now  senile  dementia. 
There  is  no  unanimity  in  either  the  medical  or  legal  conception 
of  the  term  "senile  dementia."  It  has  been  applied  to  as  slight 
an  impairment  as  weakened  memory  alone.  Some  apply  the 
term  to  that  stage  of  impairment  where  the  natural  inhibition 
upon  conduct  is  diminished  or  lost;  some  will  not  declare  a  case 
to  be  senile  dementia  until  it  has  reached  a  stage  where  it 
becomes  obvious  to  others  who  do  not  know  the  normal  mental 
condition  of  the  individual,  while  some  authorities  say  mental 
derangement  must  accompany  mental  weakness.  This  last 
conception  is  wrong,  for  in  many  cases  there  is  a  gradual  dulling 
of  the  faculties,  an  increasing  difficulty  in  recalling  events,  in 
concentrating  attention,  in  reasoning,  in  controlling  the  emo- 
tions, yet  without  mental  perversion.  If  such  an  individual 
performs  an  irrational  act  it  is  through  thoughtlessness,  lack  of 
reflection  or  impulse  and  not  through  illusions,  delusions  or 
hallucinations.  In  mental  derangement  the  individual  performs 
irrational  acts  because  he  thinks  they  are  right.  He  is  con- 
scious that  he  has  performed  certain  acts  but  his  views  concern- 
ing them  are  based  upon  false  conception  or  belief  or  false  per- 
ception with  or  without  material  basis  and  he  will  not  accept 
rational  views.  The  senile  dement  performs  his  acts  without 
false  conception  or  perception  but  rather  unconsciously  or  im- 
pulsively and  if  any  impression  can  be  made  upon  his  reasoning 
power  if  he  can  be  sufficiently  roused  to  realize  that  he  has 
performed  an  act,  he  will  recognize  its  sense  or  folly.  It  may 
be  that  owing  to  the  frequent  repetition  of  a  story  it  may  finally 
impress  itself  so  vividly  upon  the  mind  as  to  produce  therein 
the  idea  of  reality  and  thus  become  a  fixed  delusion,  but  this 
in  itself  would  not  be  a  mental  derangement.  In  old  age  the 
moral  sense  is  frequently  blunted  and  the  lessened  control  over 
conduct  may  give  rise  to  acts  of  immorality.  In  the  popular 
conception  of  the  term  insanity  these  may  be  called  insane  acts, 
they  are,  however,  not  due  to  mental  derangement  but  to  men- 
tal and  moral  weakness.  A  distinction  is  to  be  made  between 
mental  derangement  and  mental  impairment,  although  both 
may  exist  at  the  same  time. 


MEDICO-LEGAL  RELATIONS  499 

It  has  been  held  that  forgetfulness  of  recent  events  is  no 
evidence  of  incapacity  to  make  a  will.  Forgetting  the  name 
of  a  member  of  the  family  does  not  imply  such  extensive  mental 
impairment  as  to  incapacitate  the  individual,  but  to  forget  the 
existence  of  a  member  of  a  family,  especially  if  the  person  for- 
gotten has  not  been  absent  sufficiently  long  to  explain  such  for- 
getfulness, denotes  profound  mental  weakness.  It  is  always 
difficult  to  determine  whether  the  omission  from  the  provisions 
of  a  will  of  one  having  a  natural  claim  upon  the  testator  was 
intention  or  the  result  of  defective  memory.  Occasional 
absent-mindedness  due  to  mental  concentration  is  no  evidence 
of  mental  weakness,  but  persistent  absent-mindedness  or  day 
dreaming,  not  due  to  mental  concentration,  shows  profound 
mental  impairment.  To  what  extent  this  would  affect  the 
judgment  of  the  individual  while  drawing  up  a  will  will  depend 
upon  his  condition  at  the  time.  It  is  sometimes  possible  to 
arouse  mental  activity  temporarily  and  maintain  prolonged 
attention,  under  special  stimulus,  as  when  in  danger  or  when 
facing  some  grave  responsibility.  Under  such  circumstances 
the  individual  would  be  in  the  same  mental  condition  as  dur- 
ing the  lucid  interval  of  paresis. 

Judgment  may  be  impaired  in  certain  directions  without 
affecting  the  disposing  capacity,  as  where  peculiarities  and  idio- 
syncrasies exist  which  do  not  impair  the  individual's  memory 
or  judgment  as  to  the  extent  of  his  property  and  his  obligations 
to  his  family.  Hamilton  says  "the  senile  dement  is  prone  to 
make  foolish  and  trivial  disposition  of  his  property  and  par- 
ticularly is  this  the  case  when  he  is  aided  by  designing  people 
who  surround  him,  and  the  individual  of  this  kind  is  very  apt  to 
be  easily  turned  from  his  original  purpose  by  fresh  suggestions 
or  new  influences.  He  is  liable  to  imposition  and  unjustifiable 
prejudice."  The  question  of  senile  dementia  depends  upon  the 
questioner's  conception  of  the  extent  of  the  individual's  mental 
impairment,  evidenced  by  weakened  memory,  reasoning  power 
and  volition,  as  compared  with  the  mental  condition  of  the 
individual  when  at  its  best.  In  determining  the  extent  of  im- 
pairment it  is  necessary  to  compare  all  the  faculties  with  the 
faculties  as  they  were  and  not  with  the  faculties  of  another  of 
the  same  age.  It  is  necessary  to  determine  the  form  of  demen- 
tia.    The   dementia   of   cerebral   atrophy   is   progressive    and 


r00  MEDICO-LEGAL    RELATIONS 

deepening  while  the  post-apoplectic  dementia  is  most  marked 
immediately  after  the  individual  is  roused  after  the  attack, 
and  gradually  improves  as  the  physical  condition  improves. 
The  dementia  of  cerebral  arteriosclerosis  proceeds  more  slowly 
than  the  dementia  of  atrophy  or  softening  and  there  are  remis- 
sions. The  dementia  of  cerebral  softening  is  progressive  and 
proceeds  rapidly  to  complete  obliteration  of  mentality.  These 
would  all  be  classed  as  senile  dementia  yet  they  differ  in  the 
extent  and  permanence  of  the  mental  impairment.  A  year 
after  the  recognition  of  senile  dementia  due  to  atrophy,  the 
mind  may  still  be  sufficiently  alert  to  understand  and  determine 
the  provisions  of  the  instrument  that  is  being  drawn.  If  it  is 
a  case  of  dementia  due  to  softening  a  year  after  its  inception 
(the  embolic  or  thrombotic  stroke)  the  mind  is  so  profoundly 
impaired  as  to  be  incapable  of  comprehending  the  acts  per- 
formed. A  year  after  an  apoplectic  stroke  the  mind  is  com- 
paratively clear.  If  a  will  is  made  a  year  after  the  appearance 
of  the  manifestations  of  dementia  due  to  cerebral  arterio- 
sclerosis, it  will  be  necessary  to  determine  whether  the  will  was 
made  during  a  lucid  interval  or  not.  Not  only  is  the  dementia 
of.  arteriosclerosis  profound  but  it  is  often  associated  with  delu- 
sions or  illusions.  The  terminal  dementia  which  may  occur  in 
old  age  is  the  closing  stage  of  other  forms  of  insanity  and  needs 
no  further  comment,  for  there  is  no  question  about  the  testa- 
mentary incapacity  when  insanity  has  advanced  to  this  stage. 
Various  forms  of  insanity  may  appear  in  the  aged  but  they  are 
generally  carried  over  from  earlier  life  and  are  in  an  advanced 
stage  when  the  individual  reaches  old  age.  Certain  forms  of 
mental  derangement  are  peculiar  to  old  age.  Oikeiomania,  an 
unreasonable  hatred  of  one  or  more  members  of  the  family,  is 
a  rather  frequent  form  of  mental  aberration.  Beginning  in  a 
real  or  fancied  slight  or  neglect  on  the  part  of  some  member  of 
the  family,  the  individual  broods  over  it,  dislike  is  aroused  which 
develops  into  hatred,  sometimes  involving  several  members  of 
the  family.  Later  fears  and  persecutory  delusions  follow.  The 
individual  may  be  rational  in  every  other  direction  but  this 
one  delusion  impairs  his  judgment  in  one  of  the  most  vital 
points  involved,  namely,  in  making  a  will.  (Contrary  decisions 
have  been  rendered,  however.)  A  will  may  be  valid  if  an  exist- 
ing delusion  does  not  interfere  with  the  disposition  of  the  prop- 


MEDICO-LEGAL  RELATIONS  501 

erty.  Delusions  of  grandeur  are  almost  invariably  associated 
with  delusions  of  wealth,  making  the  individual  incapable  of 
comprehending  the  real  extent  of  his  property.  Where  this 
exists  the  will  shows  internal  evidence  of  mental  derangement. 
The  paranoic  forms  natural  sequences  and  draws  logical  con- 
clusions from  a  basic  proposition  which  is  an  insane  delusion. 
In  his  will  he  makes  a  rational  disposition  of  his  property, 
selects  proper  beneficiaries  but  he  will  dispose  of  vast  sums  he 
does  not  possess.  A  will  made  by  a  paretic  during  a  lucid  in- 
terval gives  no  evidence  of  insanity  and  unless  other  factors 
exist  to  invalidate  it,  it  will  be  admitted.  If  made  during  an 
insane  period  it  is  incoherent,  containing  irrelevant  comments, 
trivial  bequests  and  other  evidences  of  mental  derangement. 
The  disease,  however,  is  rare  in  old  age  and  when  it  occurs,  the 
dementia  proceeds  rapidly,  rendering  the  individual  virtually 
incapable  of  making  a  will.  As  the  mind  becomes  weakened, 
insane  ideas  become  less  extravagant,  imagination  is  less  active 
and  there  is  mental  confusion.  Confusional  insanity  with  and 
without  delusions  and  hallucinations  is  occasionally  found  in 
the  aged.  In  these  cases  mental  concentration  is  impossible  and 
the  individual  is  incapable  of  making  a  coherent  will. 

What  has  been  said  of  wills  applies  as  well  to  other  contracts 
and  documents.  The  law  does  not  recognize  senile  dementia 
other  than  as  a  form  of  insanity.  The  individual  is  either  sane 
or  insane,  competent  or  incompetent,  having  sufficient  mental 
capacity  to  make  him  responsible  for  his  acts  and  make  such 
acts  represent  his  purpose  and  intent,  or  having  not  sufficient 
mental  capacity  to  make  him  responsible  for  his  acts  and  the 
acts  valid.  There  is  no  border  state  in  law,  as  there  is  in  the 
medical  aspect  of  the  mental  condition  of  insipient  senile  demen- 
tia and  other  conditions  which  we  call  the  border  state.  The 
aged  in  the  incipient  stage  of  dementia  frequently  perform  acts 
the  nature  of  which  they  comprehend,  but  the  consequences  of 
which  they  cannot  realize,  owing  to  weakened  mentality. 
Opposing  views  have  been  expressed  as  to  the  responsibility 
of  the  individual  in  this  state  and  personal  opinion,  sentiment 
and  public  policy  toward  such  acts,  rather  than  the  medical 
view  of  the  mental  condition,  determine  the  nature  of  the  act 
and  the  responsibility  of  the  individual  performing  it.  A  factor 
heretofore  unrecognized  in  determining  the  state  of  mind  of 


-02  MEDICO-LEGAL    RELATIONS 

an  aged  person  is  the  profound  change  in  mentality  during  the 
senile  climacteric.  The  senile  climacteric  marks  the  transitional 
period  from  old  age  to  senility  and  while  it  is  in  progress,  various 
forms  of  insanity  may  appear.  This  critical  period  lasts  for 
several  months  and  as  there  are  many  lucid  intervals  during 
this  time,  failure  to  recognize  it  will  result  in  differences  in  the 
opinions  of  examiners  who  may  see  the  individual  passing 
through  this  stage,  at  different  times.  The  mind  is  exceptionally 
clear  during  a  lucid  interval  but  if  there  has  been  considerable 
mental  strain,  as  would  occur  when  under  prolonged  examina- 
tion, mental  confusion  appears  and  this  is  followed  by  delusions, 
maniacal  outbursts,  fits  of  depression,  of  crying  or  anger,  confused 
or  lost  memory  and  perverted  reason  or  judgment.  There  is 
no  evidence  of  logical  deduction,  no  rational  or  regular  sequence 
in  the  character  or  order  of  these  manifestations  of  insanity. 
Delusions  are  soon  forgotten  and  new  ones  appear.  There  may 
be  emotional  exaltation  at  one  moment,  followed  the  next  by 
calmness  or  depression.  Memory  is  confused,  recent  and  early 
events  commingling  and  forming  composite  pictures  which  may 
give  rise  to  delusions.  During  the  senile  climacteric  there  is 
sometimes  a  recrudescence  of  sexual  desire  which  is  not  sup- 
pressed by  reason  or  the  sense  of  morals  and  this  may  give  rise 
to  sexual  crimes.  Oikiomania  frequently  develops  during  this 
time.  Delusions  of  grandeur  may  arise  but  they  are  not  the 
extravagant  delusions  found  in  paresis  or  paranoia,  but  rather 
exaggerated  ideas  of  the  indiivdual's  importance  or  deeds.  As 
the  climacteric  period  gradually  merges  into  the  post-climacteric 
period  or  true  senility,  exaltation  and  depression  give  way  to 
apathy,  memory  becomes  more  unstable,  the  reasoning  power 
and  judgment  become  weaker,  delusions  and  other  manifestations 
of  mental  derangement  disappear  and  there  is  instead  a  progres- 
sive senile  dementia.  Undue  influence  is  most  frequently 
charged  in  senile  cases  and  is  based  either  upon  temperamental 
supineness,  intellectual  impairment  or  weakened  volition. 
The  individual  may  be  sane  in  every  respect  and  it  may  be  an 
evidence  of  his  sanity  that  in  order  to  be  free  from  opposition, 
annoyance  and  worry  he  will  leave  to  others  the  disposition  of 
his  property  after  his  death.  Under  such  circumstances  the 
testator  may  make  an  error  of  judgment  but  there  can  be  no 
question   as   to   his   intent   or    testamentary   capacity.     Cases 


MARRIAGE  503 

arise  in  which  an  aged  individual,  neglected  by  his  family  and 
cared  for  by  strangers,  makes  the  latter  his  beneficiaries. 
Such  cases  frequently  lead  to  the  charge  of  undue  influence. 
If  it  can  be  shown  that  such  strangers  had  poisoned  his  mind 
against  his  family,  the  inference  is  clear  that  they  had  designs 
upon  the  property  and  had  used  undue  influence  to  obtain  it. 
The  case  is  different  when  the  claimants  are  nephews  or  nieces 
or  relatives  still  further  removed,  the  testator  had  peculiarities 
which  would  have  made  him  objectionable  to  them,  and  the 
persons  taking  care  of  him  had  done  so  in  spite  of  the  peculiarities 
and  had  given  him  the  attention  which  made  him  comfortable 
during  his  life.  Where  undue  influence  is  charged  and  intel- 
lectual impairment  is  shown,  the  decision  will  rest  upon  the 
extent  of  the  mental  impairment.  The  impariment  may  not 
be  sufficiently  marked  as  to  destroy  testamentary  capacity, 
yet  it  may  be  sufficient  to  cause  the  individual  to  be  easily  turned 
from  one  purpose  to  another  by  suggestions  of  designing  persons. 
Where  weakened  volition  exists  the  individual  will  submit  to 
insistent  demands  though  made  in  the  guise  of  suggestions.  In 
these  cases  there  is  impaired  judgment  exhibited  in  the  more  or 
less  complete  dependence  upon  the  judgment  of  others  even  in 
trivial  matters.  Where  this  condition  exists  a  will  drawn  by 
the  testator  in  favor  of  the  person  dominating  him,  and  to  the 
exclusion  of  others  who  have  natural  claims  upon  the  testator, 
will  be  open  to  the  charge  of  undue  influence. 

MARRIAGE 

Most  states  have  laws  granting  divorce  or  making  mar- 
riage voidable  or  void  on  the  grounds  of  insanity  or  physical 
incapacity  at  the  time  of  marriage.  One  or  the  other  of  these 
causes  is  sometimes  introduced  to  secure  annullment  of  mar- 
riage with  an  aged  person.  The  question  of  insanity  generally 
hinges  upon  the  construction  placed  upon  senile  dementia  as  a 
form  of  insanity  and  to  what  extent  the  physiological  deteriora- 
tion of  the  mind  due  to  age  has  affected  the  reasoning  faculties. 
This  is  discussed  in  the  article  on  insanity. 

Mesalliances  occasionally  involve  legal  questions  respecting 
the  mental  capacity  of, an  aged  person  contracting  such  mar- 
riage.    In   most   cases   such   marriages   are   contracted   under 


.nA  MEDICO-LEGAL    RELATIONS 

sexual  stress,  the  individual  finding  in  marriage  the  only  means 
of  gratifying  unimpaired  sexual  desires.  In  the  absence  of 
other  evidences  of  insanity  a  mesalliance  does  not  show  mental 
deterioration. 

Physical  incapacity  may  be  organic  or  functional,  i.e.,  due 
to  defective  organs  or  to  weakness  in  the  power  of  erection. 
The  law  demands  that  it  be  shown  that  the  incapacity  is  in- 
curable.    In  the  coeundi  impotentia  senilis  and  in  other  forms 
of  functional  incapacity  it  is  often  possible  to  produce  a  tempor- 
ary   improvement    under    appropriate    treatment,    though    in 
senile  cases  we  cannot  expect  to  maintain  this  improvement 
for  any  length  of  time.     The  weakness  of  the  erectile  power 
keeps  pace  with  or  may  proceed  faster  than  the  gradual  weaken- 
ing of  the  organism  and  cure  in  the  sense  of  complete  restora- 
tion to  the  power  of  virile  manhood  is  impossible.     As  the  legal 
construction  of  the  term  "incurable,"  as  applied  to  the  annull- 
ment  statutes  of  this  state  (New  York)  has  not  been  decided, 
a  nice  question  of  law  is  raised  whether  the  requirement  of  in- 
curability will  hold,   notwithstanding  possible  temporary  im- 
provement.    In    other    words    does    temporary    improvement 
vitiate  the  sense  of  incurability.     To  the  medical  mind  com- 
plete restoration  of  a  normal  function  where  that  function  was 
impaired  or  prevented  implies  a  cure  whether  the  restoration 
be  temporary  or  permanent.     Physical  functional  incapacity 
may  be  a  relative  impotence,  the  erectile  power  being  impaired 
at  certain  times,  under  certain  circumstances  or  in  the  presence 
of  certain  persons  and  not  otherwise.     This  may  occur  in  old 
age.     From  a  medical  standpoint  it  is  impossible  to  declare 
functional  incapacity  incurable  if  the  organs  are  normal. 

SEXUAL  PERVERSIONS 

Sexual  perversions  are  rather  common  in  the  aged  and  are 
due  to  either  diminished  power  with  undiminished  desire  or  to 
a  recrudescence  of  desire  after  power  and  desire  had  previously 
disappeared.  The  latter  is  generally  a  forerunner  or  early 
concomitant  of  senile  dementia.  The  most  prolific  causes  of 
sexual  perversion  in  the  young,  depravity  and  inverted  sexu- 
ality, are  so  rare  in  old  age,  that  they  can  be  practically  elimin- 
ated.    In  the  aged  the  causes  are  weakened  mentality,  dimin- 


SEXUAL   PERVERSIONS  505 

ished  control  over  the  emotions  and  some  circumstance  produc- 
ing intense  emotional  excitement. 

Hypererosis  due  to  recrudescence  of  desire  leads  to  impul- 
sive acts  like  rape,  especially  upon  children,  and  to  bestiality. 
The  offender  does  not  realize  the  seriousness  of  his  act  nor  does 
he  seem  to  show  much  concern  when  caught  in  flagrante  delicto. 
Close  investigation  into  the  mental  condition  of  such  offender 
will  usually  reveal  mental  defects  involving  the  reasoning 
power,  the  emotions  and  the  will.  In  almost  every  case  there 
has  been  a  clean  record  without  any  evidence  of  moral  degen- 
eracy until  the  commission  of  the  crime.  A  peculiar  feature  of 
such  offences  is  that  the  offender  almost  invariably  selects  a 
child  about  the  age  of  puberty  or  younger,  rarely  an  older  one 
with  whom  the  sexual  act  could  be  performed.  These  cases 
generally  go  to  trial  and  unless  the  point  is  brought  out  that 
there  is  senile  dementia,  the  offender  is  usually  convicted. 
The  following  is  a  typical  case. 

An  inmate  of  a  soldiers'  home  who  had  not  been  away  from 
the  institution  for  several  years  visited  a  relative  in  the  city. 
During  the  night  he  entered  the  room  of  a  fourteen-year-old 
girl  and  attempted  to  assault  her.  The  child  ran  screaming  to 
her  parents,  who  found  the  old  man  undressed  in  the  child's 
room,  although  he  had  had  plenty  of  time  to  get  back  to  his 
own  room  during  her  absence.  At  the  trial  he  denied  all  knowl- 
edge of  being  in  the  child's  room  and  of  the  attempted  assault. 
There  was  no  mark  of  assault  upon  the  child  and  the  defense 
lay  in  discrediting  the  child's  testimony. 

He  was  discharged  through  disagreement  of  the  jury.  The 
following  day  he  practised  masturbation  in  a  physician's  office 
during  the  absence  of  the  latter  and  did  not  desist  when  the 
physician  returned.  Although  he  gave  evidences  of  failing 
memory  and  other  mental  impairment  at  the  trial,  his  attorney 
failed  to  take  advantage  of  this  line  of  defense. 

Outbursts  of  sexual  fury  during  such  recrudescence  are 
liable  to  recur  and  for  that  reason  where  one  has  been  guilty  of 
an  assault  he  should  be  kept  under  restraint. 

Where  the  reasoning  faculty  is  unimpaired  the  individual 
knows  that  assault  is  a  heinous  offence  which  is  followed  by 
punishment.  Even  during  an  outburst  of  sexual  fury  with 
diminished  restraint  upon  the  sexual  instinct,  this  knowledge 


(-05  MEDICO-LEGAL    RELATIONS 

saves  him  from  committing  the  crime  of  rape,  but  it  does  not 
restrain  him  from  bestiality  and  this  is  the  usual  form  of  sexual 
perversion  occurring  during  the  recrudescence  of  desire  in  the 
aged.  This  rarely  comes  to  light.  In  most  cases  the  individual 
is  unable  to  perform  the  sexual  act  and  adopts  extraordinary 
measures  to  gratify  his  desire.  In  one  case  an  aged  manufac- 
turer was  found  nude  surrounded  by  a  number  of  young  women 
in  like  condition.  When  caught  in  the  act  he  did  not  exhibit 
the  slightest  concern  about  his  situation,  yet  he  was  able  to 
conduct  the  affairs  of  a  large  factory  and  other  commercial 
interests.  Taken  to  a  sanitarium  he  soon  developed  senile 
dementia  with  occasional  sexual  recrudescences.  In  another 
case  a  merchant  was  found  by  one  of  his  family  in  a  position 
depicted  in  a  pornograph  a  number  of  which  he  had  lying  in 
front  of  him.  The  sight  of  these  pictures  aroused  in  him  in- 
tense sexual  excitement  which  he  could  not  suppress  or  gratify. 
Thereafter  the  man  was  constantly  guarded,  he  developed  an 
oikeiomania  (hatred  of  family),  later  obsession  of  persecution 
and  senile  paranoia. 

The  other  class  of  cases  of  sexual  perversion,  those  in  which 
there  is  gradual  loss  of  power  with  undiminished  desire  rarely 
lead  to  impulsive  acts,  as  outbursts  of  sexual  fury  do  not  occur. 
These  cases  lead  to  solitary  vice,  occasionally  to  bestiality, 
more  often  to  marriage  with  an  unsuitable  person. 

In  this  class  of  cases  there  is  no  dementia  and  the  individual, 
realizing  his  unfortunate  condition,  will  often  go  to  a  physician 
for  relief,  invariably  seeking  restoration  of  power,  never  suppres- 
sion of  desire.  The  marital  relations  sometimes  involve  legal 
questions,  but  the  other  perversions  are  carried  on  so  secretly 
that  they  are  rarely  discovered.  Efforts  to  prove  insanity  by 
showing  an  unsuitable  marriage  have  been  made  but  unless 
there  are  other  evidences  of  mental  impairment,  this  alone  is 
not  sufficient  to  establish  insanity. 

MALINGERERS 

Malingerers  are  frequently  found  among  the  aged,  who 
either  feign  disease  or  exaggerate  symptoms  of  an  existing 
disease  to  create  sympathy.  The  so-called  factitious  diseases 
which  are  produced  voluntarily  by  the  patient  are  rare  among 


MALINGERERS  S°7 

the  aged,  nor  do  the  aged  purposely  aggravate  their  ailments. 
They  dread  the  infliction  of  pain  and  will  do  nothing  which 
might  give  pain  or  increase  it,  or  endanger  their  lives.  As 
most  of  them  have  slight  aches  and  pains,  a  little  stiffness  in 
their  joints,  a  little  difficulty  of  sight  and  hearing,  they  exag- 
gerate their  symptoms  and  in  the  weakened  state  of  their  minds 
the  constant  repetition  and  recital  of  their  exaggerated  symp- 
toms may  cause  them  to  believe  that  they  really  suffer  as  much 
as  they  say.  No  one  can  measure  the  amount  of  pain  or  dis- 
tress that  a  person  feels,  who  has  a  disease  which  is  ordinarily 
painful.  The  aged  do  not  perceive  pain  as  intensely  as  younger 
individuals,  but  they  have  a  greater  dread  of  it,  the  anticipation 
makes  them  more  sensitive  and  if  pain  is  inflicted  their  mental 
distress  is  greater.  Under  such  circumstances  a  light  tap  is 
exaggerated  into  a  blow,  a  mild  breeze  into  a  strong  draught ; 
they  cry  before  they  are  hurt  and  claim  to  suffer  all  the  pains 
that  accompany  the  real  injury.  This  is  not  real  malingering 
as  the  patient  has  the  mental  impression  of  distress  and  for  the 
same  reason  the  hysteric  should  not  be  classed  as  a  malingerer, 
for  the  pain  is  a  mental  reality  though  there  be  no  visible  cause. 
The  true  malingerer  knows  he  tells  an  untruth  for  a  purpose 
which  will  benefit  him.  Unconscious  imitation  may  give  rise 
to  malingering.  An  aged  man  found  a  new  companion  who  had 
a  limp.  He  walked  a  short  distance  with  his  new  friend  every 
day  and  gradually  fell  into  the  step  and  limp  of  the  other. 
His  family  called  his  attention  to  his  unnatural  walk  and  the 
old  man  at  once  concluded  that  he  had  some  nervous  disease. 
He  exaggerated  his  symptoms,  limped  worse  than  ever  before 
and  when  examined  by  the  physician  he  insisted  that  he  had  a 
pain  in  the  leg.  The  physician  made  note  of  the  location  of 
the  pain  and  at  his  next  visit  read  the  record  of  the  case  as  he 
had  taken  it  but  located  the  pain  at  another  point  of  the  leg. 
The  old  man  fell  into  the  trap  but  held  on  to  the  limp.  It 
was  necessary  to  separate  him  from  his  friend,  secure  for  him  a 
new  companion  with  sound  legs  and  frighten  him  with  threats 
of  hospital  and  operation  before  he  gave  up  the  limp.  The 
aged  malingerer  is  rarely  actuated  by  fear  of  punishment  and  he 
will  not  go  to  the  length  of  those  who  will  produce  a  disease  or 
aggravate  one,  but  he  will  maintain  his  deception  even  in  the 
face  of  uncontrovertible  proof.     When  he  feigns  a  disease  it  is 


5°8 


MEDICO-LEGAL    RELATIONS 


invariably  one  in  which  pain  is  an  element,  never  one  which 
mi^ht  cause  his  removal  to  an  insane  asylum  or  a  hospital. 
The  pain  is  referred  to  his  chest  or  abdomen  rarely  to  the  back 
or  other  position  of  the  body  which  he  cannot  see.  It  is  worse 
when  the  person  believes  he  is  under  obseration,  but  when 
his  attention  is  diverted  he  gives  no  evidence  of  distress  and 
under  such  circumstances  pressure  can  be  exerted  on  parts 
which  a  moment  before  could  not  stand  the  slightest  touch. 
In  examining  a  malingerer  who  feigns  a  disease,  too  close 
investigation  and  the  appearance  of  doubt  on  the  part  of  the 
physician  will  tend  to  fix  in  the  malingerer's  mind  the  symptoms 
he  has  given  and  make  it  more  difficult  to  clear  up  the  decep- 
tion. In  cases  where  deception  is  suspected  the  physician  should 
have  an  assistant  who  without  the  knowledge  of  the  person 
makes  note  of  the  spots  where  the  patient  says  the  pains  are 
located.  By  directing  attention  to  other  portions  of  the  body  the 
malingerer  will  find  other  painful  spots  which  should  be  noted 
in  the  assistant's  record.  The  examination  should  be  superficial 
without  showing  any  doubt  in  the  person's  truthfulness.  A 
second  examination  will  usually  bring  out  new  painful  points 
while  the  malingerer  will  have  forgotten  the  location  of  the  pain- 
ful points  of  the  former  examination  or  remember  only  those  to 
which  his  attention  had  been  directed.  In  some  cases  the  patient 
will  present  the  appearance  of  decrepitude.  This  deception 
is  difficult  of  detection  by  direct  examination. 

The  person  must  be  watched  and  caught  unawares,  or  by 
arousing  his  emotions,  either  anger,  joy  or  expectancy,  a 
sufficiently  powerful  influence  may  be  exerted  to  cause  him  to 
forget  his  assumed  weakness.  Threats  of  punishment,  especially 
if  the  punishment  involves  pain,  may  cause  him  to  betray 
himself.  A  few  cases  will  be  cited.  A  man  aged  seventy-four 
applied  to  the  courts  to  compel  one  of  his  children  to  support 
him.  He  presented  the  appearance  of  extreme  decrepitude, 
tottering  along  on  his  cane  and  requiring  the  assistance  of  a 
court  attendent  to  help  him  to  the  witness  chair.  The  case 
was  decided  against  him  and  he  was  ordered  out  of  the  court 
room  under  threat  of  arrest.  He  went  out  without  his  cane 
and  as  spry  as  a  young  person.  The  aged  mother  of  a  prisoner 
appeared  on  the  witness  stand,  her  apparent  weakness  and 
scarcely  audible  voice  arousing  sympathy  for  her  and  her  son. 


MALINGERERS  5°9 

When  a  later  witness  appeared  against  her  son  she  abused 
him  in  a  loud  voice  and  it  required  some  force  to  drag  her 
from  the  court  room.  A  woman  aged  seventy  was  receiving 
sick  benefit  from  a  society  for  total  disability.  She  was  ap- 
parently too  feeble  to  walk  and  could  go  out  only  when  assisted. 
A  fire  occurring  in  her  house,  she  ran  down  two  flights  of  stairs 
then  remembering  that  she  had  forgotten  something  she  ran 
back  to  her  rooms  and  came  out  a  second  time  alone. 

The  aged  frequently  exaggerate  the  symptoms  of  minor 
ailments  and  unless  they  give  unusual  symptoms  it  is  almost 
impossible  to  detect  the  deception.  Occasionally  a  single  dose 
of  some  disagreeable  drug  will  cure  the  patient  or  make  the 
symptoms  so  mild  that  the  dose  need  not  be  repeated.  It  is 
barbarous  to  apply  a  painful  test  to  an  aged  person  suspected  of 
malingering,  as  his  purpose  is  usually  nothing  else  than  to  gain 
more  sympathy  and  attention.  There  are  occasions  when  the 
threat  of  a  painful  test  is  justifiable,  as  when  an  aged  person 
complains  that  he  is  being  neglected  by  his  family  in  spite  of 
their  most  solicitous  care  of  him,  and  spreads  the  charge  broad- 
casr  that  they  refuse  to  obtain  for  him  medical  attention,  though 
there  is  nothing  to  indicate  that  he  is  ill  except  his  complaints. 
Even  here  it  is  a  question  of  humanity  how  far  such  threats 
should  be  carried  out  and  how  far  the  person  should  be  humored. 
It  is  safe  to  say  that  when  the  patient  will  take  disagreeable 
medicine  and  will  submit  to  painful  tests  there  is  some  basis  for 
his  complaints. 


INDEX 


Abasia,  senile,  14,  147 

trepedante,  147 
Abscess,  atheromatous,  80 

brain,  476 

liver,  459 

lung,  293 

retropharyngeal,  439 

spleen,  463 
Achylia  gastrica,  186 
Acne  sclerotisans,  244 
Adams-Stokes  disease,  170 
Ageing,  causes  of,  38 

manifestations  of,  1 1 
Air  embolus,  163 
Albumin,  deficiency  in  blood,  431 
Albuminuria,  466 
Alopecia,  132 

Alternating  arrhythmia,  173 
Alternating  cerebral  anemia  and  hyper- 
emia, 193 
Amentia,  252 
Anal  fissure,  113 

sphincter,  atony  of,  113 
Anatomical     changes     in     senescence, 

21 
Anemia  and  hyperemia,  376 
Anemia,  cerebral,  193 

general,  429 

pernicious,  432 
Anesthesia,  153 

gustatory,  152 
Angina  pectoris,  174 

sine  dolore,  175 
Angioma,  senile,  231 
Angioneuroses,  242 
Anidrosis,  134 
Anorexia,  186 
Anosmia,  152 
Anuria,  465 
Aortic  aneurysm,  83 

arteriosclerosis,  82,  84 

insufficiency,  306 

stenosis,  309 
Aortite  aigu6,  80 
Aortitis,  83 

Apoplexy,  cerebral,  198 
Appearance,  13 
Appetite,  105,  186 
Arcus  senilis,  14,  36 
Arrhythmia,  171 

alternating,  173 

complete,  171 

exaggerated  respiratory,  171 

extrasystolic,  172 

galloping,  173 

sinus,  171 

transmittory,  172 


Arterial  changes,  25 

degeneration,  79 
Arteriosclerosis,  25,  74-94 

abdominal,  86 

aortic,  82 

cerebral,  84 

coronary,  83 

gastro-intestinal,  86 

hepatic,  86 

peripheral,  87 

pulmonary,  84 

spinal,  87 
Arthrosclerosis,  136 
Ascites,  461 
Asthma,  208 

Atheromatous  abscess,  80 
Attitude,  14 

Auricular  fibrillation,  171 
Autointoxication  theory  of  ageing,  41 

Bacterial  dermatoses,  239 
Biliary  obstruction,  189,  329 
Bladder  carcinoma,  282 

changes  in  senescence,  29,  34 

degeneration,  117 

dilatation,  117 

inflammation  (see  Cystitis) 
Blood  in  senescence,  33 

in  senile  cachexia,  68 

pressure,  32,  52,  81 
Bone  changes,  21 

tuberculosis,  416 
Brachial  neuralgia,  267 
Bradycardia,  168 
Brain,  abscess  of,  476 

atrophy  of,  29 

changes,  29,  35,  140 

degeneration,  138 

fag,  35  (see  also  Cerebral) 
Breast,  carcinoma  of,  284 
Bromidrosis,  134 
Bronchial  asthma,  208 

stenosis,  446 
Bronchiectasis,  287 
Bronchitis,  acute,  444 

capillary,  220 

chronic  hypertrophic,  286 

senile  atrophic,  178 
Bronchocele,  443 
Brown  atrophy,  99 
Bulbar  paralysis,  acute,  379 

progressive,  379 
Bulimia,  186 

Cachexia  Grawitz,  284 
malarial,  387 
senile,  67 


511 


5i2 


INDEX 


Calculus,  renal,  337 

vesical,  340 
Canites,  133 

Canstatt's  theory  of  senescence,  43 
Carbuncle,  240 
Carcinoma,  268 

bladder,  282 

breast,  284 

female  genital  organs,  283 

gall  bladder,  280 

intestines,  277 

larynx,  272 

lip,  270 

liver,  279 

lung,  273 

mediastinum,  274 

mouth,  271 

oesophagus,  274 

oral,  270 

pancreas,  280 

penis,  283 

prostate,  281 

rectum,  277 

scrotum,  283 

stomach,  275 

testicle,  282 

thyroid,  443 
Cardiac  asthma,  208 

dilatation;  296 

diseases,  treatment  of,  317 

hypertrophy,  25,  294 

neuroses,  166 

thrombus,  160  (see  also  Heart) 
Cardiovascular  disease,  74 
Cartilage  changes,  23 
Causes  of  ageing,  38 
Cell  evolution  theory,  43 
Cerebral  anemia,  193 

alternating  anemia  and  hyperemia, 

193 

hyperemia,  376 

apoplexy,  198 

arteriosclerosis,  84 

diseases,  56,  475 

hemorrhage,  198 

softening,  195  (see  also  Brain) 
Cerebrospinal  meningitis,  417 
Childhood  and  old  age,  1 
Cholecystitis,  189 
Cholelithiasis,  188 
Cholera,  390 
Cholerine,  391 
Chorea,  264 

Cirrhosis  of  the  liver,  456 
Circular  insanity,  256 
Circulatory  changes,  32 
Classification  of  diseases,  65 
Claudication,  87 
Climacteric  senile,  18 
Colic,  biliary,  189 
Colitis,  227,  455 
Colonic  pouch,  28,  34 
Compression  myelitis,  474 
Conception  of  old  age,  17 


Constipation,  55,  no 

Contracture      tabetique,      progressive 

atheromateux,  147 
Coronary  arteriosclerosis,  83 
Coxitis,  348 

Countenance  in  old  age,  17 
Cranial  bone  changes,  22 
Cystitis,  acute,  342 

chronic,  341 

senile,  228 

Debility,  senile,  67 
Degeneration  of  the  bladder,  117 

of  the  brain,  138 

of  the  cord,  145 

of  the  cranial  nerves,  151 

of  the  ductless  glands,  127 

of  the  end  organs,  150 

of  the  female  genitals,  124 

of  the  gall  bladder,  115 

of  the  heart,  95 

of  the  intestines,  no 

of  the  kidneys,  116 

of  the  liver,  114 

of  the  lungs,  101 

of  the  male  genitals,  120 

of  the  muscle,  134 

of  the  nerves,  150 

of  the  oral  cavity,  104 

of  the  prostate,  122 

of  the  skin,  130 

of  the  spleen,  128 

of  the  stomach,  106 

of  the  thyroid,  129 
Delirium  cordis,  171 

senile,  142 
Demange's  theory,  40 
Dementia,  acute,  252 

senile,  138,  251,  496 
Dermatoses,  bacterial,  239 

glandular,  243 

parasitic,  239 

progressive,  243 

retrogressive,  243 

toxic,  238 

tubercular,  241 
Diabetes  mellitus,  358 

complications,  374 
temporary,  359 

insipidus,  265 
Diagnosis  in  senile  cases,  51 
Diarrhea,  catarrhal,  227 

senile,  55,  226 

serous,  227 
Digestion  changes,  27,  34 
Dilatation  of  bladder,  117 

of  stomach,  108 
Diphtheria,  384 
Disseminated  sclerosis,  149 
Dress,  491,  493 
Dribbling  urine,  118 
Drugs  in  old  age,  58 
Ductless  glands,  degeneration,  127 

diseases  of,  443,  444 


INDEX 


513 


Duodenal  ulcer,  450 
Durand  Fardels  theory,  41 
Dysentery,  388 
Dyspepsia,  106 
Dysphagia,  105 
Dyspnea  in  emphysema,  102 
Dyspragia  intermittens  angiosclerotica 
intestinale,  87 

Ear  changes  in  senescence,  30 

symptoms  in  arteriosclerosis,  85 
Ecthema,  239 
Eczema,  236 
Edema  hypostatic,  95 

laryngeal,  441 

pulmonary,  288 
Electrotherapy,  62 
Embolic  cerebral  softening,  196 
Embolism,  air,  163 

cerebral,  196 

femoral,  163 

portal,  163 

pulmonary,  162 

renal,  163 
Embryocardia,  173 
Emphysema,  senile,  101 
Empyema,  210 

End  organs,  degeneration,  150 
Endocarditis,  acute,  403 

senile,  100 
Endothelial  irritation,  78 
Enteritis,  450 

acute,  451 

chronic,  454 
Enteroliths,  322 
Enteroptosis,  321 
Epilepsy,  262 
Epithelioma,  247 
Erysipelas,  419 
Exercise,  481 
Exophthalmic  goitre,  443 
Extrasystolic  arrhythmia,  171 
Eye  changes  in  senescence,  30,  36,  53 

symptoms  in  arteriosclerosis,  85 

Pace  in  senile  diseases,  53 
Facial  nerve,  degeneration  of  1 5 1 
Fatty  degeneration  of  the  heart,  300 
of  the  liver,  459 

infiltration  of  the  heart,  301 
Fear  in  the  aged,  486 
Fecal  impaction,  322 
Female  genital  organs,  carcinoma,  283 

changes,  16 

degeneration,  124 
Femoral  embolism,  163 
Fibroma,  246 
Flatulence,  113 
Folliculitis,  240,  244 
Food,  112,  183,  368,  478 
Furuncles,  240 

Gall  bladder  carcinoma,  280 
changes,  28 

33 


Gall  bladder,  degeneration,  115 

inflammation,  189 
Gall  stones,  188 
Gangrene,  pulmonary,  290 

senile,  164 
Gastralgia,  187 
Gastric  asthma,  208 

atonicity,  106 

carcinoma,  275 

catarrh,  senile,  180 

hyperesthesia,  186 

neuroses,  185 

ulcer,  448 
Gastritis,  acute,  223 

chronic,  225 
Gastrodynia,  187 

Gastro-intestinal  arteriosclerosis,  86 
Gastrospasm,  185  (see  also  Stomach) 
Generative   organs,    female,    degenera- 
tion of,  124 
male,  degeneration  of,  120 
Glandular  changes,  29 

dermatoses,  243 
Glossodynia,  105 
Glossopharyngeal   nerve,    degeneration 

of,  151 
Goitre,  exophthalmic,  443 
Gonorrheal  infection,  425 
Gout,  351 

irregular,  356 

regular,  352 

retrocedent,  352 
Goutiness,  356 
Grawitz'  cachexia,  284 
Gustatory  anesthesia,  152 

paresthesia,  153 

Hay  fever,  207 
Heart  block,  172 

brown  atrophy,  99 

changes,  25,  26,  32 

degeneration,  95 

fatty  degeneration,  300 
infiltration,  301 

neuroses,  166  (see  also  Cardiac) 
Heat  regulation  in  senescence,  42 
Heberden's  nodes,  348 
Hematuria,  466 
Hemicrania,  246 
Hemoglobinemia,  431 
Hemoglobinuria,  466 
Hemorrhoids,  327 
Hepatic  abscess,  459 

arteriosclerosis,  86 
Hernia,  326 
Hidrocystoma,  243 
Histomechanical  theory,  40 
Histopathological  theory,  40 
Hobbies,  484 

Home  care  of  the  aged,  476 
Horsley's  theory,  42 
Hydremia,  430 
Hydropneumothorax,  292 
Hydrotherapy,  62 


5J4 

Hygiene,  476 
Hyperesthesia,  154 
Hyperidrosis,  134 
Hypertrichosis,  133 
Hypochlorhydria,  186 
Hypochondria,  252 
Hypostatic  edema,  95 
Hysteria,  264 
Hysterical  asthma,  208 

Illusions  in  arteriosclerosis,  85 
Impaction,  intestinal,  322 
Impetigo,  239 

contagiosa,  236 
Impotence,  120 
Infarction  spleen,  463 
Infectious  diseases,  382 
Influenza,  401 
Insanity,  496 

circular,  256 
Insomnia,  61,  265 
Institutional  care  of  the  aged,  4S5 
Intestinal  carcinoma,  277 

catarrh,  227 

changes,  28 

degeneration,  no 

growths,  323,  326 

impaction,  322 

neuralgia,  188 

obstruction,  320 

occlusion,  325 

paresis,  323 

stenosis,  320 
Ischial  neuralgia,  267 

Keloid,  246 

Keratoma,  232 

Kidney  changes,  17,  28,  33 

degeneration,  116     M 

hyperemia,  464  (see  also  Renal) 
Kinks,  326 
Kyphosis,  15,  1 7 

Larynx,  carcinoma  of,  272 
edema  of,  441 

inflammation  of,  acute,  440 
chronic,  285 
subacute,  441 
neuroses  of,  442 
paralysis  of,  442 
spasms  of,  442 
syphilis  of,  441 
tuberculosis  of,  441 
Lentigo,  249 
Leukemia,  434 
Ligaments,  changes,  24 
Lipoma,  246 
Liver  abscess,  459 
amyloid,  459 
carcinoma,  279 
changes,  28 
cirrhosis,  456 
degeneration,  114 
fatty  degeneration,  459 


INDEX 


Liver  hyperemia,  458  . 

syphilis,  458  (see  also  Hepatic) 
Lorand's  theory,  42 
Lung,  abscess,  293 

carcinoma,  273 

changes,  27,  31 

degeneration,  101 

gangrene,  290 

tuberculosis,   411     (see   also   Pul- 
monary) 
Lupus,  241 

Malaria,  386 
Malarial  cachexia,  387 
Malingerers,  506 
Mania,  255  , 

Marasmus,  Schoenlein  s,  72 
Marriage,  502 
Maxilla  changes,  22 
Measles,  384 
Mechanotherapy,  63 
Mediastinal  cancer,  274 
Medico-legal  relations,  495 
Melancholia,  252 
Meniere's  symptom  complex,  471 
Meningitis,  cerebrospinal,  417 
purulent,  476 
tubercular,  476 
Menopause,  16 
Mental  changes,  14  37» 
in  climacteric,  19 
disease  symptoms,  56 
stimulation,  477,  482 
weakness,  38 
Metchnikoff's  theory,  41 
Metritis,  191 
Metrorrhagia,  342 
Miliaria,  243 
Miliary  tuberculosis,  415 
Minot's  theory,  43 
Mitral  insufficiency,  311 

stenosis,  313 
Modified  diseases  of  old  age,  206 
Morbus  coxae  senilis,  348 
Motor  oculi  nerve  degeneration,  151 
Mouth  carcinoma,  271 
Mumps,  386 
Muscle  changes,  13,  24 
degeneration,  134 
Muscular  atrophy,  progressive,  471 
Murmurs,  54 
Myalgia,  468 
Myelitis,  acute,  474 
compression,  474 
senile,  146 
Myocarditis,  98 
Myofibrosis,  96 
Myositis,  470 
Myxedema,  443 

Naunyn's  theory,  42 
Neoplasms,  benign,  246 

malignant,  247 
Nephritis,  acute,  467 


INDEX 


515 


Nephritis,  chronic  interstitial,  332 

parenchymatous,  467 
Nerve  changes,  30 

degeneration,  150 
Nervous  diseases,  symptoms,  56 

system  changes,  35 
Neuralgia,  brachial,  267 

intestinal,  188 

ischial,  267 

occipital,  267 

trifacial,  204,  266 
Neurasthenia,  259 
Neuritis,  203 
Neuroses,  cardiac,  166 

gastric,  185 

intestinal,  188 

laryngeal,  442 

oesophageal,  187 

of  the  aged,  264 

throat,  439 
Nevi,  246 

Occipital  neuralgia,  267 
Oesophageal  cancer,  274 

neuroses,  187 

spasm, 187 
Oikeiomania,  477,  479 
Oligemia,  429 

Optic  nerve  degeneration,  151 
Oral  cavity  degeneration,  104 

carcinoma,  270 
Ortner's  syndrome,  87 
Osteitis  deformans,  350 
Osteomalacia,  472 
Osteomyelitis,  474 
Osteoporosis,  21 

Pachymeningitis,  475 
Paget's  disease,  350 
Pain,  53 
Palpitation,  167 
Pancreas  carcinoma,  280 

changes,  28 
Pancreatitis,  462 
Paralysis  agitans,  377 

sine  tremore,  378 

bulbar,  acute,  381 
progressive,  379 
pseudo,  381 
Paranoia,  256 
Paraplegia,  146 
Paratyphoid,  399 
Paresis,  general,  255 
Paresthesia,  150 

gustatory,  153 
Parorexia,  186 
Parosmia,  152 
Pastimes,  488 
Pelvic  changes,  22 
Pericarditis,  447 
Perichondritis,  440 
Perisplenitis,  463 
Peritonitis,  acute,  460 


Peritonitis,  chronic,  461 
Pernicious  anemia,  432 
Pernio,  238 
Pertussis,  386 
Phagocytosis  theory,  41 
Pharyngitis,  438 
Phlebosclerosis,  94 
Phthisis  fibroid,  412 
Physiological  changes,  31 
Pigment  deposits,  131 
Pityriasis,  238 
Plague,  390 
Pleural  cancer,  273 
Pleurisy,  209 
Pneumokoniosis,  103 
Pneumonia,  infectious,  405 

senile,  216 
Pneumothorax,  292 
Pneumotosis,  185 
Polyneuritis,  471 
Portal  embolism,  163 
Presbyacusia,  35,  36,  153 
Presbyopia,  35,  36,  153 
Preferential  diseases  of  old  age,  268 
Primary  senile  diseases,  67 
Proctitis,  455 
Progressive  bulbar  paralysis,  379 

muscular  atrophy,  471 
enfeeblement,  135 
Prostate,  atrophy,  124 

carcinoma,  281 

degeneration,  122 

hypertrophy,  122 
Prurigo,  238 
Pruritus  senile,  154 
Psoriasis,  238 
Pseudo  debility,  69 
Pseudo  insomnia,  265 
Pseudo  Paget's  disease,  135 
Psychasthenia,  257 
Psychic  changes,  37 

senile  debility,  69 
Psychoses,  251,  255 
Pulmonary  abscess,  293 

asthma,  208 

carcinoma,  273 

changes,  27,  31 

congestion,  214 

edema,  288 

embolus,  162 

gangrene,  290 

hyperemia,  214    (see  also  Lung) 
Pulse,  32,  52 

in  arteriosclerosis,  81 
Purpura  senile,  230 
Pyelitis,  468 
Pyemia,  421 
Pylorus,  insufficiency,  109 

relaxation,  185 
Pyopneumothorax,  292 
Pyrosis,  185 
Pyuria,  467 

Raynaud's  disease,  87 


5i6 

Rectal  carcinoma,  277 
Reflexes,  36,  54 
Relapsing  fever,  417 
Renal  calculus,  337 

embolism,  163 
Respiratory  changes,  27,  31 
Retropharyngeal  abscess,  439 
Rheumatic  arthritis,  346 
abortive,  348 
multiple,  347 
Rheumatism,  acute,  419 

chronic,  344 
Rhinitis,  acute,  436 

chronic,  437 
Rosacea,  234 


Sarcoma,  249 
Scarlatina,  383 
Schoenlein's  marasmus,  72 
Scrotal  carcinoma,  283 
Sebaceous  naevi,  232 
Second  sight,  36 
Secondary  senile  diseases,  157 
Senile  climacteric,  18 

slouch,  70 

stoop,  70 

tremor,  148  (see  also  terms  having 
Senile  as  prefix) 
Sensations,  36,  53 
Sepsis,  421 
Septicemia,  421 
Sex  perversions,  503 
Sight  impairment,  36 
Sinus  arrhythmia,  171 

thrombus,  159 
Skin  changes,  24 

degenerations  of,  130 

diseases  of,  229 (see  also  Dermatoses) 
Sleep,  483 
Smell,  30,  36 
Social  intercourse,  488 
Spinal  column  changes,  23 

cord  changes,  30 
degeneration  of,  145 
diseases  of,  474 
Spleen  changes,  28 

degeneration  of,  128 

diseases,  463 
Splenoptosis,  463 
Spondylitis  deformans,  348 
Stature,  14,  23 
Stomach,  atonicity,  106 

carcinoma  of,  275 

changes,  27,  34 

degeneration  of,  106 

dilatation  of,  108  (see  also  Gastric) 
Sudariperous  glands,   degeneration  of, 

134 

Suprarenal  glands,  degeneration  of,  129 

diseases  of,  444 
Syphilis,  426 

larynx,  441 

liver,  458 

throat,  439 


INDEX 


Tachycardia,  169 
Taste,  36 
Teeth,  105 

Temperamental  changes,  37 
Temperature  in  disease,  52 
Tendon  reflexes,  36 
Theories  of  ageing,  39 

autointoxication,  41 

Canstatt's,  43 

cell  evolution,  43 

defective  heat  regulation,  42 

Demange's,  40 

Durand  Fardel's,  41 

glandular,  42 

Horsley's,  42 

histomechanical,  40 

imperfect  repair,  42 

Lorand's,  42 

Metchnikoffs,  41 

Minot's,  43 

Naunyn's,  42 

phagocyte,  41 

Thoma's,  40,  75 

unstable  metabolism,  42 

vital  principle,  40 

wear  and  tear,  39 
Thoracic  changes,  23 
Throat,  diseases  of,  438 
Thrombosis,  157 

cardiac,  160 

sinus,  159 

venous,  159 
Thrombotic  softening  of  brain,  195 
Thyroid  degeneration,  129 

diseases,  443 
Tongue  cancer,  271 
Tonsillitis,  439 

Transmittory  arrhythmia,  172 
Treatment  in  senile  cases,  58 
Tremor  senile,  148 
Tricuspid  insufficiency,  314 
Trifacial  neuralgia,  151,  204 
Tubercular  dermatoses,  241 
Tuberculosis,  411 

acute  general,  415 

bone,  416 

laryngeal,  441 

meningeal,  476 

miliary,  415 

throat,  439 
Typhoid  fever,  392 
Typhus  fever,  399 

Ulcer,  chronic,  244 

duodenal,  450 

gastric,  448 
Unstable  metabolism,  42 
Uremia,  465 
Urine  changes,  33 

dribbling,  118 
Urolithiasis,  337 

Vagus  degeneration,  151 
Valvular  lesions,  302 


INDEX 

Variola,  391  Warts,  233 

Varioloid,  392  Wear  and  tear  theory,  39 

Vascular  changes,  25  Weil's  theory,  77 

Veins  varicose,  156  Whooping  cough,  386 

Venosity,  27  Wills,  495 

Venous  thrombus,  159  Wrinkles,  131 

Vesical  calculus,  340 

Vicious  circles,  35  Yellow  fever,  387 

Vincent's  angina,  438 

Vital  principle  theory,  40  Zoster,  senile,  242 

Volvulus,  326 


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